Lodging Application

Cancer Support Community's Lodging Assistance Program
To make sure that your application is eligible for consideration, the following documents need to be included:
- A signed and dated letter (on letterhead) confirming your diagnosis and need for local lodging for treatment from a medical professional on your treatment team
  - Physician, nurse practitioner, or physician assistant
  - Nurse navigator
  - Patient navigator
  - Social worker
- Proof of residence (e.g., utility bill, copy of ID, driver's license, or like documentation)
If you fail to honor your reservation without providing prior notice or explanation, you will become ineligible for any future lodging support services from the CSC.
Contact Information
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Preferred phone*
Secondary phone
Proof of residence (e.g. utility bill, copy of ID, drivers license, or like documentation). If you are unable to upload file please email to lodging@cancersupportanrabor.org or fax to 734-975-2525.

Proof must be submitted in order for your application to be reviewed.
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Email address*
example@example.com
Medical Information
Name of person with cancer*

First NameLast Name
Date of birth of person with cancer*

MonthDayYear
Type of cancer*
Stage of cancer:*

0IIIIIIIV
Cancer treatment center*
Treating physician's name*
Treating physician's office phone number
A signed and dated letter (on letterhead) stating the number of days needed for lodging for cancer related treatments. If you are unable to upload file please email to lodging@cancersupportanrabor.org or fax to 734-975-2525.

Letter must be submitted in order for your application to be reviewed.
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Hotel Stay Information
Expected arrival date*

MonthDayYear
Expected departure date*

MonthDayYear
Number of beds needed*
Names of any other individuals staying in the room
Any additional requests (i.e. handicap room, dog friendly, etc.):
Statement of Income
Total number of people in the household*
Number of working adults in household*
Number of children/dependents in household*
Monthly household income before expenses*
Demographic Information

The following questions are optional and will in no way affect your eligibility for lodging assistance.
Race (please check all that apply)*

American Indian or Alaska NativeAsianBlack or African-AmericanWhiteNative Hawaiian or other Pacific IslanderDon't wish to answerOther
Ethnicity*

HispanicNon-HispanicDon't wish to answer
Gender Identity*

ManWomanTransgender womanTransgender manNonbinaryDon't wish to answerOther
Insurance Type*

MedicaidMedicareMedicare + PrivatePrivateUninsuredDon't wish to answer
Certification and Consent
I hereby certify, under penalty of perjury, that the information set forth on this application is true and accurate and that the expenses for which I have requested financial assistance/lodging assistance impose a financial hardship for me. I understand that only the expenses approved through this application are covered. Further, myself or my loved one has been diagnosed with cancer, I/they are undergoing treatment for, or are in recovery from recent treatment for cancer, and do not have adequate resources or income to pay for the expenses. I understand that if any of the information set forth above is false, that my application will be null and void. Additionally, I understand that any tax implications are my responsibility and the Cancer Support Community does not provide any information directly to me for tax purposes.

By signing below, I hereby grant and give permission for representatives of the Cancer Support Community of Greater Ann Arbor to contact my physician(s) and/or medical team member(s) as needed.
Signature*

Clear
Date*

MonthDayYear
Should be Empty:

Cancer Support Community's Lodging Assistance Program

Contact Information

Medical Information

Hotel Stay Information

Statement of Income

Demographic Information

Certification and Consent