2026 Holiday Hope Recipient Application

2026 Holiday Hope Recipient Application

Please complete this application for yourself or a loved one to be considered for Holiday Hope 2026. Holiday Hope is designed to support families who have a parent in active cancer treatment over the holidays. Please note that the deadline to submit this application is OCTOBER 16TH, 2026. *******PLEASE NOTE: At this time, Holiday Hope is only available to applicants residing in the Central Pennsylvania region.
Personal Information

Please include all personal information. If you are filling this out for a loved one, please indicate that you are filling this form out for someone else.
I am filling this form out for:
If you are filling this out for a loved one, please include your email.
example@example.com
If you are filling this out for someone else, indicate your relationship to the applicant.
IMPORTANT: If you're filling this form out for someone else, please list the applicant's contact information, NOT your own
Patient name:

First NameLast Name
Patient date of birth:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Patient address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Patient email:
example@example.com
Patient phone number:
Please enter a valid phone number.Format: (000) 000-0000.
Please list all immediate family member's living in the patient's home including their names, ages, and relations to the patient:
Example: Tom, age 40, husband. Susie, age 9, daughter. Ben, age 7, son.
What is the primary language spoken in the home?
Diagnosis and Treatment Verification

Please include all necessary information to be considered for assistance.
Cancer Type/Diagnosis:
Date of Diagnosis:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Describe the patient's current treatment plan:
What hospital is the recipient currently in treatment at?
Who is the patient's treating oncologist?
Does the patient have a social worker? If so, what is their name?
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 the patient's employment status?
What is the patient's household income range?
Please explain the patient's financial situation if they are unable to work:
Does the patient rent or own their home?
What is the patient's monthly rent/mortgage payment?
What other assistance does the patient, or has the patient received received?
If you do not receive any other type of assistance, please type "NA" in the box.
Is the patient eligible for public assistance? Please explain:
Patient Statement of Need
Please describe the patient's current financial situation, and how this holiday giving program would help:
Please explain in detail what the patient's greatest need is right now.
This information helps us allocate resources appropriately and fairly to all applicants.
If the patient has a CaringBridge or Facebook page, please share the link so we can follow their story:
How did you hear about Radiant Hope's Holiday Hope Program?
Primary Contact Information

Holiday Hope requires a consistent and reliable primary contact. This person will be responsible for direct communication with the Radiant Hope team, and will be involved in creating a wishlist for the recipient's family. This person can be the patient, a family member, a trusted friend, etc. Please provide the primary contact person's information below.
Primary contact name:

First NameLast Name
Relation to patient:
Primary contact phone number:
Please enter a valid phone number.Format: (000) 000-0000.
Primary contact email:
example@example.com
What is the best way to reach the primary contact?
Submission Information

Approved applicants will be contacted directly. If additional information is needed to process your application, a member of our team will reach out using the phone number or email address provided.To help expedite the review process, please upload the requested supporting documentation with your application. PLEASE NOTE: Applications that include a physician's note verifying an active cancer diagnosis will be prioritized. Applications submitted without this documentation may experience delays in processing.
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:

Cancelof
Authorization and Consent

I authorize the Radiant Hope to contact my treatment facility for verification and understand that assistance is subject to availability and intended purpose. By signing below, I affirm the information provided is accurate. If my information is false, I will not be granted assistance.
Patient Signature
Should be Empty:

2026 Holiday Hope Recipient Application

Personal Information

Diagnosis and Treatment Verification

Financial Information

Patient Statement of Need

Primary Contact Information

Submission Information

Authorization and Consent