• WICKLUND WARRIORS, INC.

    FINANCIAL ASSISTANCE APPLICATION

    • We are committed to supporting individuals who, despite maintaining financial stability before their diagnosis, face temporary unemployment during treatment. Recognizing the importance of these transitional phases, we aim to provide financial assistance to help individuals and their families bridge the gap, so they can focus on their well-being without the added financial burden.

    • All Applicants Must:

      • Reside and have maintained uninterrupted residency for 12 months in Albany, Columbia, Greene, Fulton, Montgomery, Rensselaer, Saratoga, Schenectady, Schoharie, Warren, or Washington counties.
      • Be at or below an annual gross income of 500% of the Federal Poverty Guidelines (QR code for guidance) and demonstrate a substantial loss of income due to a blood cancer diagnosis.
      • Have a confirmed blood cancer diagnosis from an accredited medical center, referred to us by that institution's social worker or a member of its medical staff. Signed by the Clinical Licensed Advocate at the patient's treatment center.
      • Signed and properly attested by the Patient/Guardian.
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  • Applicant Information

    If under 18, please complete as Guardian.
  • Date of Birth
     - -
    2 digit month, 2 digit day, 4 digit year
  •  -
  • Have you lived at this address for 12 months or greater:*

  • Parent/Spouse/Caregiver Information

    The person that lives with you that helps with care.
  •  -

  • Blood Cancer Diagnosis Information

  • Relapse?
  • Need a transplant?
  • Where will you have your transplant?

  • Do you have other major medical issues hindering your recovery?
  • Do you smoke?

  • Health Insurance Info

  • Do you have insurance?*

  • Employment Information

    If applicant is a minor, enter caregiver/guardian information
  • Currently employed?*

  • Financials

    Combined household income. If currently unemployed due to treatment, what was your income prior to diagnosis?
  • Public Assistance

  • What are your greatest needs?

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  • Social Media Usage

    The Wicklund Warriors relies on generous donations from our supporters and sponsors. Allowing us to feature your cancer journey helps our donors understand to whom their contributions help. This connection is essential to our success and future funding. Therefore, we are asking permission to share your story on our social media platforms, events & other support collateral. We will never use your full name.
  • Facebook*
  • Instagram*

  • Applicant Attestation

    By signing this form, I attest that the information provided on this form is true and accurate to the best of my knowledge. That any grant received will be used exclusively for needs identified on this application to maintain records of use.  If requested, provide documentation of proper use of any grant and proof that the household’s annual income is equal to or less than 500% of the Federal Poverty Level.
  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year

  • Treatment Center Information

  •  -

  • Email: info@wicklundwarriors.com

    Mail: PO Box 11152, Loudonville, NY 12211

    Learn More: wicklundwarriors.com

    Facebook and Instagram: WicklundWarriors

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