AmPowering Hope: Cancer Treatment Assistance Grant Application Form
Grant Overview
AmPowering(www.ampowering.org), a non-profit dedicated to empowering communities and transforming lives, is pleased to announce the availability of grants ranging from $1,000 to $5,000, with a total fund of $15,000 to be distributed. These funds, raised from the Global Women Festival 2024 and pageant sponsorships, aim to support cancer patients from low-income families. The grant application period opens on June 28 and closes on Oct 30. Grant awardees will be notified by Nov 10. Eligibility Criteria To qualify for the AmPowering Cancer Patient Assistance Grant, applicants must meet the following criteria: Diagnosis: Confirmed diagnosis of cancer by a licensed healthcare provider. Income: From a low-income household (proof required, e.g., tax returns or pay stubs).Residency: U.S. residents. Insurance Status: Uninsured, underinsured, or facing significant out-of-pocket expenses despite having insurance. Treatment Status: Currently undergoing treatment or have a scheduled treatment plan. Financial Need: Demonstrated financial need with details of medical bills, treatment costs, and related expenses. Personal Statement: A 500-word max statement describing the situation, impact of the grant, and financial burden alleviation. Medical Reference: A reference letter from a healthcare provider involved in the applicant's cancer care.
Application Form
Applicant Information:
Full Name
*
First Name
Last Name
Date of birth
*
-
Month
-
Day
Year
Date of birth
Gender
Male
Female
Transgender
Prefer not to answer
Other
Address
*
Street Address
Street Address Line 2
City
Please Select
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California
Colorado
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Delaware
District of Columbia
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Louisiana
Maine
Maryland
Massachusetts
Michigan
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Utah
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Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Cancer Diagnosis:
Type of cancer
*
Date of Diagnosis
*
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Month
-
Day
Year
Date
Healthcare Provider
*
Proof of Diagnosis
*
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Financial Information:
Household Income
*
$0 - $24,999
$25,000 - $49,999
$50,000 - $74,999
$75,000 and above
Proof of income
*
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e.g., tax returns, pay stubs
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Insurance Status
*
Uninsured
Underinsured
Insured with high out-of-pocket costs
Details of Financial Need:
*
Specify amount and details
Financial Need Documentation
*
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Treatment Information:
Current Treatment Plan
*
Scheduled Treatment Plan
*
specify details if applicable
Proof of Treatment Plan
*
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Personal Statement:
Personal Statement (500 words max)
*
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Medical Reference:
Healthcare Provider Reference Letter
*
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Submission:
Submit application and supporting documents via email to: grants@ampowering.org Or mail them to: AmPowering Grants, 11878 175th Pl SE, Redmond, WA 98052, USA. Validation Rules All required fields must be completed. Date fields must follow the specified format. Uploaded documents must be in PDF or JPEG format and not exceed 2MB each. Email address must be valid. Phone number must follow the specified format. Selection Process All applications will be reviewed by the AmPowering Grant Committee. Selection will be based on demonstrated financial need, treatment status, and the personal statement provided. Penalties for Discrimination AmPowering has a strict non-discrimination policy. Any discrimination or harassment during the application process or grant period will result in disciplinary actions, including but not limited to disqualification from the grant, termination of any association with AmPowering, and possible legal action.
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