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)*
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 referralOnline
Are you receiving assistance from any other source? If yes, please explain:*
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