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:
Patient Statement of Need
Please describe your current financial situation, and how this assistance would help you:
Please Select the Fund(s) you are applying for:
Fueled by Hope: This program is designed to ease the financial burden of a cancer diagnosis. Through Fueled by Hope, Radiant Hope provides gift cards to individuals and families affected by cancer, offering support for everyday essentials like groceries, gas, meals, and more.
Brittany Gendy Fund: In honor of beloved wife and mother, the Brittany Gendy Fund supportts families affected by cancer, ensuring they receive assistance during their time of need. It is our hope to spread the love, hope, and generosity with which Brittany led her life.
Brittney Horst Fund: This fund has been established to pass on Britt's spirit of thankfulness and assist families with the financial burdens of cancer care costs of any type, including traditional, complementary, and/or natural therapies. Britt believed in supplementing care for cancer and the importance of caring for your spiritual heart, especially seeking Christ above all.
Jenni Duncan Fund: This fund continues to ignite a flame within us to keep loving and supporting one another. Each year, on September 15th, the anniversary of our non-profit's inception, we will name a recipient who is on their journey paying forward small acts of kindness, and making purpose from their pain.
Please indicate if you are interested in any of the following programs offered by Radiant Hope:
Meal Vouchers
Respite
Family Photography
Support Group
Youth Scholarships
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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