FLORIDA AND NEW YORK FAMILIES ONLY

Grant Application

To apply, patients must be under the age of 18 and in active treatment at a U.S. hospital.

A Hope48 Fund social worker will need to contact a social worker or healthcare professional at the hospital to complete your application.

Applicant Name

First Name

Last Name

Applicant Email

Applicant Phone Number

(###)

###

####

What is the applicant’s relationship to the patient?

Parent Name (if different from above):

First Name

Last Name

Parent Email (if different from above):

Parent Phone Number

(###)

###

####

Patient Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Preferred Language

Name of Hospital/Treatment Center

Full Name of Social Worker or Healthcare Professional

First Name

Last Name

SW/HCP Title

SW/HCP Email

Direct Phone Number of SW/HCP

(###)

###

####

Patient Name

First Name

Last Name

Patient Date of Birth

YYYY

Patient Gender

Patient Race

How many people are in the patient's household?

Is this a single parent household?

Please provide more info about the household including who lives there and who contributes to the household income

Cancer Type

Tumor stage (if applicable)

Date of Diagnosis

YYYY

Is this a Relapse?

Date of Relapse?

YYYY

Phase of Treatment

Type of Insurance

Has the family used savings in the last 3 months

Has the household experienced a loss of income due to the Cancer Diagnosis

What was the household annual income last calendar year before taxes?

How many people contributed to this household income?

What is the current employment status of person 1

What is the current employment status of person 2

Has the family experienced any kind of emergency or crisis in addition to (and not related to) the cancer?

Has the family been concerned that you would not be able to pay for childcare?

Has the family been concerned about the cost of medical treatment or care? (This can include your insurance premium, any copayments, or your deductible)

Has the family ever traveled 50 or more miles each way for cancer treatment?

Has the family ever been concerned about the non-medical costs related to treatment? (Such as parking at the treatment center, meals at the treatment center, or temporary lodging near the treatment center?):

Does the family regularly rely on public transportation?

Is the family current on their car payment and car insurance?

In the past 3 months, has there been concerned that the family would run out of food?

Are one or more of the family’s utilities currently at risk for shut off?

Is the family’s phone at risk of being shut off?

Is the family concerned they will NOT have stable housing

Does the household currently pay rent or mortgage?

Long Term Disability

If the household has a rent or mortgage what is the monthly payment?

If the household has a monthly payment, are they behind? If so, how many months are they behind?

If your family owns or leases a car what is the monthly payment?

How has the family been financially impacted due to the cancer diagnosis? Is there anything else we should know for this application?