Fueling the Fight
Gas Cards for Kansas Childhood Cancer Families
Name of person requesting the card
*
First Name
Last Name
Relationship to the child
*
Please Select
Parent
Guardian
Other (please specify below)
If you selected Other, please explain
Mailing Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Child's Information
Child's Name
*
First Name
Last Name
Date of birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Child's date of birth
Diagnosis
*
Diagnosis Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date of diagnosis
Hospital
*
Hospital where you receive treatment
Physician
*
Name of treating physician
Fueling the Fight gas cards can be requested every 12 months.
Have you received a Fueling the Fight Gas Card previously
*
Yes
No
If yes, what date did you receive your gas card
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Gas Card Preference
Please Select
Casey's General Store
Shell
Doesn't matter, we can use either one.
Let us know which card will be more useful during your traveling.
How did you hear about Fueling the Fight Gas Cards
*
Please submit a letter of verification from your hospital
*
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Letter must be from the treating institution on their letterhead. The letter must include the child's full name, diagnosis and date of diagnosis. Letters can be from the treating physician, nurse, social worker or child life specialist.
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of
I acknowledge the following:
I authorize the Love, Chloe Foundation and its agents and representatives to contact the above named medical institution and physician in order to verify my child’s cancer diagnosis.
I attest that the information provided above and accompanying this application is true and correct to the best of my knowledge.
Signature
When will you receive your card
Gas cards are sent out weekly. You will be notified by email or phone when your request is received and approved! Approval of requests is dependent on available funds.
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