Millie's Light Lives On Family Assistance Application

Millie's Light Lives On Family Assistance Application

The Millie Moo Foundation exists to support families navigating pediatric cancer challenges by providing financial relief, compassion, and community support.This application helps us understand your family’s needs and allows us to share the impact of Millie’s legacy so we can continue helping other families.
Estimated time to complete: 10-15 minutes

Applications are reviewed and applicants will be contacted within 3-7 business days.

Please indiciate if this is an emergency situation.

Applications are approved on a monthly basis.

All information shared is reviewed confidentially by authorized Foundation representatives.

If you have any questions or need help filling it out, please reach out to us at familyassistance@themilliemoofoundation.org

We’re here to support you every step of the way.

Eligibility Requirements:
- Must reside the United States
- Child and Legal Guardian must be U.S. Citizens
- Child is age 26 or under
- Child has a current pediatric cancer diagnosis or is recently in remission
  - If in remission- must be within the last 12 months, and will only be eligible for travel gift cards.
- Family is experiencing financial strain related to the medical situation
- A family can apply once every six months

Date

MonthDayYear
Date
Parent/Guardian Name

First NameLast Name
Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Home Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Contact Email Address
example@example.com
Relationship to Child
Child's Full Name

First NameLast Name
Child's Date of Birth

MonthDayYear
Date

Diagnosis
Date of Diagnosis

MonthDayYear
Date
Current status
Current Treatment Center/Hospital
Social Worker Name

First NameLast Name
Social Worker Phone
Please enter a valid phone number.Format: (000) 000-0000.
Social Worker Email
example@example.com
By providing the contact information above, I authorize The Millie Moo Foundation to contact the listed medical social worker, treatment coordinator, or hospital representative solely for the purpose of verifying diagnosis and active treatment status related to this application
We ask that you provide a written statement explaining your families story. Please share any other information or special circumstances you feel are relevant to your application that should be taken into consideration by The Millie Moo Foundation. Please write your statement below:

Based on your responses throughout the application, additional supporting documentation may be required before your application can be reviewed. Please upload all requested documents below. Missing or incomplete documentation may delay processing or impact eligibility for assistance.
Driver's License

Please upload a clear photo or scan of the driver’s license.
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Mortgage statement or W9 from landlord

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Medical bill

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Utilities bill

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Eviction notice document

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Disconnect notice document

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Do you have a social media page for your child that we can follow?
How did you hear about The Millie Moo Foundation, Inc?
Terms & Conditions

By submitting this application to The Millie Moo Foundation, Inc. (“The Foundation”), you acknowledge, certify, and agree to the following:
- All information submitted is true, accurate, and complete to the best of your knowledge.
- The Foundation may request additional documentation and verify information provided, including identity, residency, diagnosis/treatment status, income, landlord/vendor information, mortgage or utility balances, and other information necessary to review the request.
- Submission of an application does not guarantee approval or funding.
- The Foundation reserves the right to approve, partially approve, deny, delay, or discontinue assistance at its sole discretion based on available funding, eligibility requirements, verification results, and program priorities.
- The Foundation may issue payments directly to landlords, mortgage companies, utility providers, medical providers, vendors, or other third parties instead of directly to applicants.
- Any false, misleading, altered, incomplete, or fraudulent information may result in denial of assistance, revocation of approved assistance, permanent disqualification from future assistance, and/or referral to appropriate authorities.
- The Foundation reserves the right to deny payments to vendors, landlords, businesses, or accounts that cannot be reasonably verified.
- Applicants understand that fraud prevention procedures may include public-record searches, ownership verification, W-9 requests, invoice verification, and payment authentication procedures.
- The Foundation, its board members, volunteers, committees, donors, affiliates, and representatives shall not be held liable for denied applications, delayed processing, vendor disputes, third-party actions, or decisions made in good faith regarding assistance requests.
- Applicants may generally apply once within a six (6) month period unless otherwise approved due to extraordinary circumstances.
- Denial of an application does not prohibit future applications if circumstances materially change or additional supporting documentation becomes available.
- Any optional authorization allowing The Foundation to share portions of a family’s story, images, or testimonials for awareness or fundraising purposes will be separately consented to and is not required for eligibility.
- Assistance provided by The Foundation is charitable in nature and may carry tax implications depending on individual circumstances. The Foundation does not provide legal, financial, medical, or tax advice.
- By signing below the acknowledgment box and submitting the application electronically, you agree that your electronic acknowledgment and signature are legally valid and equivalent to a handwritten signature.
I acknowledge that the information provided is accurate and true to the best of my knowledge:
Should be Empty: