Request Financial Aid from Kids and Cancer Benefit Run

A grant request form is available here.  You can download it, fill it out, and mail it to us. Note that Adobe PDF Reader is required. Get the latest version of the Adobe Reader here.

Or, if you prefer, you can fill out the form below and it will be emailed to us. We will contact you shortly. You can upload up to 3 documents in image format or pdf.

    KIDS AND CANCER ORGANIZATION

    Donation Request Application

    Patient Information

    (All fields required)







    Contact Information

    (If different from Patient Information)





    Request for Assistance

    Please indicate if you have a preference where you would need assistance:


    * This can be an unpaid home utility bill, a mortgage payment, rent payment, etc.
    Upload up to 3 documents if required:


    I am submitting this application on behalf of who has been diagnosed as stated above and requires assistance with the costs associated with treatment. I agree that by submitting and signing this request that all information contained herein is accurate and true to the best of my knowledge.



    Publicity Release

    Kids & Cancer organization, with the help of many volunteers and donors, is honored to be able to assist families facing financial hardships due to pediatric cancer and other life-threatening illnesses. We respectfully request the usage of your name and/or photo in releases such as Facebook, newsprint, and/or at our public events. This is not mandatory.



    Thank you for your support!

    Copyright © 2015-2021 Kids and Cancer Benefit

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