Financial Support Application
Our goal is to help ease the financial burden that often comes with a childhood cancer diagnosis. Please fill out this application to let us know how we can best support your family.
Child's Name
*
First Name
Last Name
Child's Age
*
Child's Diagnosis
*
Estimated End of Treatment
*
Hospital Child is Treated at
*
Social Worker's Name
*
First Name
Last Name
Social Worker's E-mail
*
example@example.com
Social Worker's Phone Number
Format: (000) 000-0000.
Do you give Strong Little Souls permission to contact your social worker?
*
Yes
No
Parent/Legal Guardian Name
*
First Name
Last Name
Parent's E-mail
*
example@example.com
Parent's Phone Number
*
Format: (000) 000-0000.
Permanent Mailing Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
What type of financial assistance are you requesting?
*
Gas
Groceries
Utility Bill
Transportation
Medical Co-Payments
Other (complete below)
If you selected other please let us know how we can help!
Please upload documentation confirming your child's diagnosis.
*
Browse Files
Drag and drop files here
Choose a file
Accepted forms include any document that clearly shows your child’s name, date of birth or age, and diagnosis. This can be a letter from a doctor or social worker, a MyChart screenshot, or hospital discharge paperwork. By providing this documentation, we're able to speed up the application process and offer support more efficiently.
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Feel free to share any links to support pages or social media accounts where you post updates about your child — we love following along and staying connected!
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