Hope Program Application

Objective of the Hope Program

The Hope Program is designed to help children and families affected by cancer with financial assistance for any necessities. This can include transportation, meals, lodging, bills, rent, child care, and any other necessities or treatment-related expenses.
Eligibility Guidelines
- Must be a California resident

- Demonstrate financial need

- Patient must have been diagnosed on or before his/her 21st birthday and treated before his/her 24th birthday.

- You must have less than $5,000 in easily accessible bank accounts (such as checking,savings and fundraising accounts).

Be prepared to submit proof of diagnosis with a letter from your social worker. We will contact you within 48 hours on the status of your requests. If you have any questions contact us at info@bagsoflovefoundation.com.
Patient Information:
Full Name*

First NameLast Name
Patient's Date of Birth*

MonthDayYear
Age *
Gender *
Type of Diagnosis *
Date of Diagnosis*

MonthDayYear
Date
Date(s) of Relapse
If applicable*
Expected Date of Completion of Treatment*

MonthDayYear
Date
Does the child have health insurance?*

YesNo

Parent/Guardian Information
Parent(s) Name *
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Language *

Financial Information
Is the patient filed as an independent?*

YesNo
Patient Annual Income*
i.e. government assistance, child support, alimony, family assistance, all sources of income to pay living expenses
Parent/Guardian 1 Annual Income*
i.e. government assistance, child support, alimony, family assistance, all sources of income to pay living expenses
Parent/Guardian 2 Annual Income (if applicable)
Household Size (number of people living in household)*
Number of Children in Household*
Current Financial Status*
Provide any additional details of your current financial status. (i.e.)

Social Worker Information
Name*

First NameLast Name
Email*
example@example.com
Phone Number
Please enter a valid phone number.
Hospital*
Upload Proof of Diagnosis*

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Cancelof
To help us meet your needs, the urgency of your request is needed. *Please provide the urgency of financial assistance*
Which of the following is being requested? (Check all that apply)*

TransportationLodgingRentBillsMealsOther Necessities
Intended Use of Grant?*
Grant Amount Requesting? *
Up to $1,500

How did you hear about us?*
Please Specify*
All applications will be reviewed on a case-by-case basis and a final determination will be made based upon other applications submitted to the Bags of Love Foundation and the availability of funds. You will not be discriminated against based on race, religion, color, national origin, sex or political affiliation.

If awarded a grant by Bags of Love Foundation, you may be asked to help promote our charitable efforts in an e-newsletter, brochure, press release, social media, fundraising event or similar project? PLEASE NOTE: You may always decline any opportunity we contact you about.
Parent/Guardian or Social Worker Signature *

Powered by Jotform SignSocial worker must have consent from family. Clear
Printed Name *
Relationship to Patient *
Date*

MonthDayYear
Should be Empty:

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Objective of the Hope Program

Eligibility Guidelines

Patient Information:

Parent/Guardian Information

Financial Information

Social Worker Information