Financial Aid

Child/Patient Information

Patient's First Name*

Patient's Middle Name*

Patient's Last Name*

Gender

Male

Female

Ethnicity (Check all that apply. Information will be used for statistical purposes only and will not affect eligibility.)

African American

Asian

White

Hispanic/Latino

Opt Out

Enter your own value

Date of Birth (M/D/YYYY)*

Birthplace (state/country)*

What best describes the type of community you live in? *

Patient's Address*

Patient's Address (2)*

City*

State*

Zip Code*

County*

Is patient applying for assistance independent of guardian(s)?

Yes

Parent/Guardian Information

First Name (Guardian #1)*

Last Name (Guardian #1)*

Relationship to Child (Guardian #1)

Mother

Father

Grandparent

Enter your own value

First Name (Guardian #2)*

Last Name (Guardian #2)*

Relationship to child (Guardian #2)

Mother

Father

Grandparent

Enter your own value

Primary Number*

Is Primary Number

Landline

Cell

Secondary Number*

Is Secondary Number

Landline

Cell

Email*

Can NCCS email updates to you regarding upcoming events and happenings?

Yes

Is address same as patients?

Yes

If no, address*

Address (2)*

State*

City*

Zip Code*

Do guardians speak English?

Yes

Medical Information

Hospital*

Does child have a social worker?

Yes

If yes, social workers first and last name*

Email*

Phone Number*

Mailing Address*

Dept.*

City*

State*

Zip Code*

Diagnosis

Brain Tumor

Germ Cell Tumor

Leukemia

Liver Cancer

Lymphoma

Myelodysplastic Syndrome

Neuroblastoma

Retinoblastoma

Sarcoma

Wilm’s Tumor

Enter your own value

If brain tumor, grade of tumor*

Date of diagnosis (m/d/yyyy)*

# of relapses*

Most recent date of relapse (m/d/yyyy)*

Household Income

Total annual family income ($)*

Family income sources (please check all that apply):

Salary

SSI

Child Support

TANF

Enter your own value

Guardian #1 Employer*

Is Guardian #1 on unpaid leave?

Yes

Guardian #2 Employer*

Is Guardian #2 on unpaid leave?

Yes

Banking

Do you have a bank account(s)?

Yes

Please list your checking/savings and other easily accessible accounts in the space provided. Include any fundraising accounts that have been established on behalf of your child. Copies of your most recent statements for all of the accounts below must be included. Remember, you must have less than $5,000 in easily accessible accounts to be eligible for assistance. *

Bank Name*

Account Number (Last 4 digits)*

Account Type

Checking

Savings

Fundraising

Bank Name*

Account Number (Last 4 digits)*

Account Type

Checking

Savings

Fundraising

Bank Name*

Account Number (Last 4 digits)*

Account Type

Checking

Savings

Fundraising

Do you have more than 3 bank accounts?

Yes

Insurance Information

Patients Health Insurance (check all that apply)

Private

State

Enter your own value

Funding Procedures

A case manager will contact you by phone once the application has been received and processed by the NCCS to determine how we can best assist you.*

Transportation assistance may be provided for up to 60 days. In order to request additional transportation assistance, you must have a hospital professional submit a request in writing that provides an update on your child's treatment plan. (You do NOT need to submit a new application.)*

Assistance Requested

What financial assistance are you requesting? (Please check all that apply.):

Travel Assistance Fund (TAF) - travel, lodging

Emergency Assistance Fund (EAF) - must be inpatient or relocated from home for 15 consecutive days (documented by hospital)

Consent to Release Information and Affirmation

I do hereby authorize all hospitals, financial institutions and insurance groups to release to the National Children’s Cancer Society ("NCCS"), or its duly authorized representative, any information deemed necessary to complete its investigation of my application for financial assistance. I further authorize the NCCS and its representative to provide such information to those institutions as may be reasonably required to assist our family and child. All consents given herein shall continue until such time as the undersigned provides notice of termination in writing. Financial assistance will be provided with the use of said funds to be specified by NCCS.*

The "undersigned" means the parents or guardians of the child. The undersigned acknowledge(s) and agree(s) to:*

* Return any unused funds, if requested, within fifteen (15) days to the NCCS so that those funds can be utilized by the organization to benefit other families. The NCCS will pursue restitution for grants if it is determined that the information submitted on the application is false. *

* Maintain records that will be made available to the NCCS upon reasonable request, detailing the expenditures made from the funds provided by the organization.*

* Hold harmless and release and forever discharge the NCCS from all claims, demands, liability and causes of action which the undersigned, heirs, representatives, executors, administrators, or any other persons acting on the undersigned’s behalf or on behalf of the undersigned’s estate have or may have by reason of this authorization.*

* Give continuing consent to NCCS to use images of any and all kinds of my child, myself, and our names, so long as they are only used on behalf of NCCS. I may void consent by checking the boxes below this provision and initialing it.*

Furthermore, while NCCS will make all efforts to ensure the information provided below is handled confidentially and information will only be shared as deemed necessary to complete its investigation of my application for financial assistance, NCCS cannot guarantee your information will be confidential and it may be possible that others will know what you have reported.*

I have read the guidelines for financial assistance and the eligibility checklist, and I declare that the information furnished on this application form, including attached sheets, is true and correct to the best of my knowledge.*

As the undersigned, I have read this release before signing below and I fully understand the contents, meaning, and impact of this release.*

Date (M/D/YYYY)*

*We can only speak to the parent(s)/guardian(s) that have signed this application. *

Parent/Guardian Signature*

Relationship to the patient/child:

Mother

Father

Self

Grandparent

Enter your own value

Parent/Guardian Signature*

Relationship to the patient/child:

Mother

Father

Self

Grandparent

Enter your own value

I do not give consent for media release*

*Anti-Discrimination Policy: You and your child will not be discriminated against or denied assistance because of your race, religion, color, national origin, gender or political affiliation. All financial applications will be reviewed on a case-by-case basis and final determination will be made based upon your eligibility, NCCS guidelines and the availability of funds.*

By clicking “submit,” I provide my signature expressly consenting to contact from NCCS or its subsidiaries, affiliates, or agents at the number I provided regarding products or services via live, automated or prerecorded telephone call, text message, or email. I understand that my telephone company may impose charges on me for these contacts, and I am not required to enter into this agreement as a condition of purchasing property, goods, or services. I understand that I can revoke this consent at any time.*

Application for Financial Assistance