Keris Kares Grant

Grant Application for Financial Assistance
“Rejoice always, pray without ceasing, in everything, give thanks; for this is the will of God in Christ Jesus for you.” 1 Thessalonians 5:16-18

It is our mission to provide hope for families dealing with a childhood cancer diagnosis by providing spiritual, emotional, and financial support. We will raise awareness about pediatric cancers and provide monetary assistance to research being conducted to find a cure.

In support of this mission, Keris Kares, Incorporated provides supplementary financial assistance to families with financial needs resulting from a pediatric cancer diagnosis. The grant covers non-medical costs such as rent/mortgage payments, utility bills, car loans, and car insurance payments. All checks will be made payable to the creditor or bill providers and not the parent or guardian of the child.
To Qualify for Assistance:
- The patient must be a child (under 18 years old at the time of application; D.o.B. must be included to verify).
- The patient must be undergoing treatment for pediatric cancer.
- A written statement from the doctor or Social Worker must validate the request.
- The application must include a copy of the bill that will be paid and a description (type of bill, dates of service, amount requested, remittance address, payee name, etc.).
- Families can receive one Family Assistance grant every 12 months with a maximum award of $1,500.
Financial Assistance is based on the availability of funds. Complete applications will be reviewed in the order received. All protected information is strictly confidential. Once reviewed, KKI will contact the grant submitter to confirm whether the application has been accepted or declined. Please allow five to seven business days for a response. All grant applications must be received by December 7th to be reviewed within the current calendar year.
Please send grant-related questions to grants@keriskares.org.

Only complete applications will be reviewed.

Applicant Information
Applicant's Full Name:*

First NameMiddle NameLast NameSuffix
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Phone:*
Please enter a valid phone number.
Email:*
example@example.com

Patient Information
Patient's Name:*

First NameMiddle NameLast NameSuffix
Date of Birth:*

MonthDayYear
Please provide a brief description of illness including date of diagnosis and treatment plan.*
Please list the name and contact information of your child’s primary doctor & current treatment facility. *
Please upload a copy of your diagnosis letter: *

Cancelof
Reference #1 Name:*

First NameLast Name
Best Contact Number:*
Please enter a valid phone number.
Reference #2 Name:*

First NameLast Name
Best Contact Number:*
Please enter a valid phone number.
Bill Description:*
Amount Requested:*
Payee Name:*
Please attach a copy of the bill: *

Cancelof

Is the patient and/or applicant willing to share their story about how Keris Kares has made their journey with adversity easier? If so, our Outreach Team may contact you. *Answers to this question are not considered during the grant approval process.**

YesNo
How did you hear about Keris Kares?

Social WorkerSocial MediaWebsiteIndividualOther
I hereby consent that the medical records provided may be part of my application for assistance to Keris Kares, Incorporated, or its officials. I understand that my application cannot be processed until I have submitted all required documents to the address shown on the top (or email at the bottom) of this application. By signing below, I certify that this request has been made voluntarily, that I have read and understand this application, and that the information above is accurate to the best of my knowledge.
Applicant's Signature*

Powered by Jotform SignClear
Date*

MonthDayYear
Should be Empty:

Grant Application for Financial Assistance

Applicant Information

Patient Information