Elliestrong Financial Assistance Application Form

Cancer Family Financial Assistance Application

#elliestrong forever foundation was founded by Ellie's parents after she passed in 2019 from a brain tumor. The foundation works with families fighting cancer to help financially so they can "Live on, follow their dreams" ~Ellie
Once the application is complete it will be given to the board of directors of the foundation where they will conclude if there is a need and if the foundation has the funds to provide assistance. This foundation is a small foundation that services local children and families. The foundation is based out of Lemont, IL but helps with Chicagoland area families in need of financial support. The foundation also holds a large annual fundraiser and a family is selected as the sponsored family and receives 60% of funds raised at the event.
Patient's Name*

First NameLast Name
Age of Patient (Although our focus is on children who have cancer we have helped adults in the past)*
The Elliestrong Forever Foundation offers a range of financial assistance programs for families fighting cancer, and you may qualify for more than one. Please select ALL the programs you are interested in applying for. If you have any questions about our programs, feel free to email us at Elliestrongforever@gmail.com.

Financial Assistance Programs for Families Fighting Cancer:

1.) Financial Assistance Program: This program is available for both adults and children battling cancer. We strive to support 100% of our applicants, with financial assistance ranging from $1,000 to $3,000. The funds can be used however you see fit—whether it's for medical bills, a vacation, home repairs, or everyday expenses. You can apply once a year for financial assistance as long as your family is still in treatment

Ellie’s Holiday Heroes: This program, launched in 2024, is designed for children fighting cancer and their siblings, or the children of adults battling cancer. We collaborate with a group of martial arts schools to help fulfill the kids' Christmas Wishlist. Each child can receive up to $200 worth of items. After all the gifts are purchased, you may receive a call from one of our board members to discuss adding additional items to the Wishlist.

Annual Fundraiser: We encourage ALL families who meet the following criteria to apply. We try to select one adult and one child fighting cancer to be the recipients of our annual fundraiser. Each chosen family will receive 40% of the proceeds from the event, which last year amounted to over $20,000 per family. The event is a memorable evening with live music, a DJ, and a lively dance floor. Our attendees tend to have so much fun they attend every year.

Annual Fundraiser Eligibility Criteria:

• Must be able to attend the event (we understand things can come up, but we request that at least one immediate family member attends).
• The event is held annually on the Saturday before the Super Bowl; this year, it will be on Saturday, February 8th.
• Must be within a 30-minute drive of Lemont, IL
• Must be in treatment or have a treatment plan in place.

We typically have over 300 attendees, and the support from the chosen families is crucial. If you have strong family or community backing, it increases the potential to raise more funds, which can be used for anything your family needs—whether it’s medical bills, a vacation, home repairs, or other expenses.

Be sure to complete the additional questions in the application marked "Annual Fundraiser Application." We will narrow down to 4-5 finalists and then a board member will reach out to speak to you before bringing your family for a vote to be chosen as the board.
Choose ALL that you wish to apply for:

Financial Assistance ProgramEllie's Holiday HeroesAnnual Fundraiser (would be for 2026 we already have the recipients of the 2025)
Parents 1 Name*

First NameLast Name
Parent 2 Name (if applicable)

First NameLast Name
Phone Number*

Area CodePhone Number
Cell Phone Number*

Area CodePhone Number
Email*
example@example.com
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cancer Diagnosis*
Please put specific diagnosis, type of cancer
Date of Diagnosis*

MonthDayYear
Date
Oncologists Name*
Treatment Hospital*
Is there a care page, website, Facebook page for the patient? Please list all*
Currently in treatmentFinished TreatmentFinished Treatment more than 5 years ago
Date completed treatment (if applicable)

MonthDayYear
Date
Brief description of treatment plan or past treatment?*
Please provide a description of patient's treatment, how often, how long, as much detail as possible....
Briefly describe your story*
This brief description will be used on our website. For examples please see elliestrongforever.com
Photo of Patient*

Browse Files
If chosen to receive funds this photo will be used on our website with a brief descriptions of the patient's story. Cancelof
How did you hear about #elliestrong forever?*

HospitalFriendBoard/committee member referralOnlineOther
Are you receiving assistance from any other source? If yes, please explain:*
Next 3 Question:

Are for those families applying to be chosen to be the receipent of our

Annual Fundraiser
1.) Do you live 30 minutes from Lemont, IL

YesNo, but I feel like I will be able to get the support for the event even though it is further away.No, and I don't feel like my family and friends will make the trip for the event.
2.)Do you come from a very supportive family or community? Do you feel like you would be able to ensure that at least 50 supporters would attend? Please elaborate.
3.) Will the family member being treated for cancer still be in treatment in February 2025? Please elaborate
Authorization to Release Information

I hereby authorize Elliestrong forever foundation (ESF) and its representatives or agents to contact my child’s physician, medical institution or facility, medical insurance company or the provider of services for the bill(s) for which I am seeking reimbursement or payment in order to verify the charges incurred and to verify whether the charges are related to my child’s cancer diagnosis.
I also hereby authorize   (name(s) of physicians and/or contact at hospital)
First Name*   Last Name*   ,   First Name   Last Name
at (Institution or provider's name)   Hospital or treatment center?*
to release information and records to Elliestrong forever foundation and its representatives or agents with regard to my child or patient    patient's name*
as ESF may request of said physicians, institution, or provider.
Todays Date*

MonthDayYear
Date
Signature*

Clear
Signature

Clear
Todays Date*

MonthDayYear
Date
Should be Empty:

Cancer Family Financial Assistance Application