Valerie Carr Compassion Program
Assistance Request Form
The Valerie Carr Compassion Program provides financial assistance to Union County residents who must travel outside the county for cancer treatment. All information submitted through this form will be kept confidential and used solely for the purpose of reviewing assistance requests through the Valerie Carr Compassion Program.
Applicant Information
Full Name*
*
Date of Birth*
*
-
Month
-
Day
Year
Date
Address*
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
ZIP Code*
*
Phone Number*
*
Format: (000) 000-0000.
Email Address
example@example.com
Preferred Method of Contact*
*
Phone
Email
Eligibility
Are you a resident of Union County, Arkansas?*
*
Yes
No
Are you currently undergoing cancer treatment or scheduled to begin treatment?*
*
Yes
No
Do you travel outside Union County to receive treatment?*
*
Yes
No
Treatment Travel Information
Name of Treatment Facility*
*
City and State of Treatment Facility*
*
How often do you travel for treatment?*
*
Weekly
Bi-Weekly
Monthly
Other
Approximately how far do you travel for treatment?*
*
Less than 50 miles
50-100 miles
101-250 miles
More than 250 miles
About Your Request
Briefly describe your current situation and how travel for treatment has affected you or your family.*
*
Back
Next
How would assistance from the Valerie Carr Compassion Program help you at this time?
*
Optional Information
Is there anything else you would like the review committee to know?
Certification
I certify that the information provided is true and accurate to the best of my knowledge.
I understand that submission of this request does not guarantee financial assistance.
Electronic Signature
*
Date
-
Month
-
Day
Year
Date
Preview PDF
Submit
Should be Empty: