Application for Assistance
Radiant Hope offers financial support to those whose lives have been impacted by cancer. Please complete this application to request assistance through one or more of our programs. Please note that in order for applications to be considered, you must upload a note from your treating oncologist.
Personal Information
Please include all personal information.
Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Oncology Center and Physician:
Diagnosis and Treatment Verification
Please include all necessary information to be considered for assistance.
Cancer Type/Diagnosis
Describe your current treatment plan:
Who is your treating oncologist?
Oncologist or Social Worker Email:
example@example.com
Financial Information
We ask for this information so we can steward our donor-funded resources responsibly and serve families with the greatest need. This helps us distribute support fairly and in alignment with our mission. All information shared is kept confidential and used only to determine eligibility.
What is your employment status?
What is your household income range?
$0-50,000
$50,000-100,000
$100,000-150,000
$150,000+
Please explain your financial situation if you are unable to work:
Do you rent or own your home?
Rent
Own
What is your monthly rent/mortgage payment?
Do you have health insurance?
Please Select
Yes
No
Primary insurance company:
What other assistance do you, or have you received?
If you do not receive any other type of assistance, please type "NA" in the box.
Please list the names and ages of all the individuals living in your household:
Are you eligible for public assistance? Please explain:
Please indicate if you are interested in any of the following programs offered by Radiant Hope:
Meal Vouchers: Provides 5 fresh, nutritious meals (Clean Eatz, Camp Hill) per chemo cycle to patients in active chemotherapy who are facing financial, social, and nutritional distress.
Free Care Package: Designed to uplift and encourage anyone as they navigate cancer.
Respite Care: Designed to offer rest and rejuvenation to you and your family as you navigate cancer.
Family Photography: Catch forever memories with free photography sessions.
Support Group: Our support groups offer community for patients, caregivers, and survivors in their journey.
Youth Scholarships: Designed to provide a sense of normalcy for children who have a family member in treatment.
Fueled by Hope: Offers gas and grocery cards to ease daily burdens.
Brittany Gendy Fund: Scholarship award designed to relieve financial burdens; awarded every April and December.
Brittney Horst Fund: Scholarship award designed to relieve financial burdens; awarded every January.
Jenni Duncan Fund: Scholarship award designed to relieve financial burdens; awarded every September.
Patient Statement of Need
Please describe your current financial situation, and how this assistance would help you:
If you have a CaringBridge or Facebook page, please share the link so we can follow your story:
Submission Information
If you prefer not to submit electronically, please submit completed applications via mail to: Radiant Hope, Attn: Fueled by Hope, 48 Central Blvd. Camp Hill, PA 17011. Applications are reviewed every two weeks. Approved applicants will be contacted directly. If additional information is needed, we will reach out to you at the phone number or email you provided. We also ask that you upload the following documents so we can approve your application quicker:
Doctor's note and signature:
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Recent paystub OR disability check:
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Last year's W-2, OR a recent bank statement:
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Authorization and Consent
I authorize the Radiant Hope to contact my treatment facility for verification and understand thatassistance is subject to availability and intended purpose. By signing below, I affirm the informationprovided is accurate. If my information is false, I will not be granted assistance.
Patient Signature
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