Comfort Kit & Wellness Request Form

Healthcare Comfort Kit, Transportation & Wellness Request Form

Comfort Kits are for patients and caregivers in the United States battling cancer or supporting someone in their fight against cancer. Each package is personalized and includes items to help support and comfort families through this journey. Additional information may be requested. Deliveries will only be made to addresses in Southern Illinois provided on this form. Due to the high demand for our Comfort Kit, requests may be subject to a waiting list. Please allow 14 days for processing. Send any questions to info@fightingcancertoday.org.
Who will be the recipient of the Comfort Kits? *

Patient Caregiver
Type of Cancer(s) recipients are being treated for. *
How Many Comfort Kit's Are You Requesting? *
Please select quantity being requested?
How Many Gas Cards Are You Requesting? *
Gas cards are issued in $10 increments.
Business Name *
Business Phone Number *

Area Code Phone Number
Office Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Contact Person *

First Name Last Name
Job Title *
Company E-mail *
Who will accept delivery of goods requested? *

Help Support the Fight Against Cancer by Donating Today!

USD

By requesting and submitting this form you agree to submit to Fighting Cancer Today within 90 days of reciept of Comfort Kit's the Microsoft Excel Spreedsheet (this will be emailed upon approval) that outlines important demographics of the receipents of Comfort Kits, allowing us to continue receiving funding. Additionally, you are agreeing to not resale or accept services in exchange of the products being donated by Fighting Cancer Today for the sole purpose of offering emotional and financial support of families battling cancer.

If there are any questions or concerns please email info@fightingcancertoday.org or call directly our office at 618-922-0585 and someone from our team will follow-up with you shortly.

All requests are subject to approval, by submitting this form it does
Name of person submitting this form? *

First Name Last Name
Should be Empty:

Healthcare Comfort Kit, Transportation & Wellness Request Form