Financial Assistance Application
The All For Dave Foundation was created in memory of Dave, whose life embodied compassion, generosity, and the belief that service to others should come first. Inspired by his 14-year battle with ocular melanoma and his commitment to helping others, our foundation strives to ease the financial burdens by individuals and families navigating cancer. We understand that every journey is different. This application gives you the opportunity to share your story, explain your current needs, and help us understand how financial assistance could make a meaningful difference in your life. Thank you for allowing us to learn more about you. We are honored to consider your application.
Applicants Name
*
First Name
Last Name
Are you applying for yourself or someone else?
*
Myself
Spouse/Partner
Child
Parent
Other
Cancer type (if known):
Feel free to explain
Has cancer created a financial hardship for you or your household?
*
Yes
No
Have you received assistance from All For Dave Foundation before?
*
Yes
No
If yes, when and for what purpose?
Are you receiving or have you applied for assistance for these same expenses elsewhere?
*
Yes
No
If yes, please explain...
Back
Next
About You and Your Household
Full Legal Name
*
First Name
Last Name
Preferred Name
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Age
*
Mailing Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Preferred Contact method:
*
Phone
Email
Mail
Number of people in your household:
*
Number of dependents you financially support:
*
Please describe your household and family situation. Include any caregiving responsibilities or family circumstances you would like us to consider.
*
Have children or other dependents been affected by the diagnosis, treatment, or related financial hardship? If yes, please explain.
*
Back
Next
Employment and Financial Information
Share only what is relevant to assessing your request. Do not include Social Security numbers or bank account details.
Current employment status:
*
Full-time
Part-time
Self-employed
Unemployed
Medical leave
Unable to work due to medical reasons
Retired
Other
Employer Name (if applicable):
Job title / occupation:
Has cancer, treatment, or caregiving affected your ability to work?
*
Yes
No
If yes, describe any reduced hours, unpaid leave, job loss, or other changes
Approximate total monthly household income before taxes:
*
Under $2,000
$2,000 - $3,999
$4,000 - $5,999
$6,000 - $7,999
$8,000 or more
Prefer to discuss privately
Has household income changed because of cancer or treatment?
*
Yes
No
If yes, please explain the change and when it began.
Are there other circumstances affected your financial stability that you would like us to consider?
Back
Next
Medical Journey and Requested Assistance
Provide only the medical details needed to understand the request. Supporting documents may be requested separately.
Name of person diagnosed (if different from applicant):
*
Cancer type:
*
Approximate date of diagnosis:
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Current care status:
*
Active treatment
Follow-up/surveillance
Clinical trial
Recovering from treatment
Ongoing cancer-related care
Other
Briefly explain how the diagnosis or treatment has affected your or your family.
*
What type of financial assistance are you requesting? Check all that apply:
*
Medical bills, deductibles, or coypayments
Prescription medication or medical supplies
Travel to treatment or clinical trials
Hotel or temporary lodging during treatment
Prosthetic eye or ocular prosthetic care
Transportation to medical appointments
Household bills affected by cancer-related loss of income
Other
Total amount requested:
*
When is assistance needed?
*
Immediately
Within 30 days
Within 60 days
Within 90 days
Itemized expenses:
*
Rows
Expense/purpose
Amount
Due date (if known)
Expense 1
Expense 2
Expense 3
Have any listed expenses already been paid?
*
Yes
No
Partially
Have you sought assistance from insurance, government programs, or other nonprofits for these expenses? Please describe any assistance received or pending.
*
How would receiving assistance make a difference for you or your family?
*
Back
Next
Your Story
Answer in your own words.
Please share your cancer journey. When did cancer become part of your life, and what has the experience been like for you and your family?
*
What has been the most difficult part of this journey - financially, physically, emotionally, or within your family?
*
What has helped you keep going? Who or what has been an important source of support?
*
What are you looking forward to, working towards, or hoping to accomplish for yourself or your family?
*
Is there anything else you would like the review committee to know?
Back
Next
Service Above Self
Dave believed in helping others and making a difference through kindness and generosity. We recognize that every person has different circumstances and abilities. Your answers are an opportunity to share your values - not a promise or requirement to volunteer, donate, or repay assistance.
What does "service above self" mean to you personally?
*
How have you experienced kindness or support from others during your journey?
*
If you are able, how might you hope to pay that kindness forward now or in the future?
*
What are your personal goals, aspirations, or dreams for the future?
*
Is there a cause, community, or group of people you hope to help or inspire one day?
*
What would receiving assistance from All For Dave Foundation allow you to focus on or work toward?
*
Back
Next
Supporting Documents and Medical Information
The Foundation may request reasonable documentation relevant to eligibility and the specific expense. Please do not send original documents unless requested.
Medical Information Authorization - Important
This application is not itself a HIPAA authorization or a blanket waiver of privacy rights. If the Foundation needs protected health information directly from a healthcare provider, it will provide a separate authorization identifying the information to be disclosed, who may disclose it, who may receive it, the purpose, and the expiration date or event. The applicant may ask questions before signing and may revoke authorization as permitted by law, subject to actions already taken in reliance on it. The Foundation will limit access to authorized individuals and handle information according to applicable law and its privacy practices.
*
I understand that the Foundation may request a separate, specific information authorization if needed.
Applicants name:
*
Signature
*
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Back
Next
Next Step: Virtual Meeting or Personal Video
We believe every story deserves to be heard. A written application helps us understand your circumstances, and a personal conversation can help us get to know you beyond the paperwork. If invited to the next round, you may be offered a Zoom or Google Meet conversation with Foundation representatives. You may invite family members or loved ones if you wish. Alternatively, you may submit a personal video by email. A video does not need professional equipment or editing.
If invited to the next round, which format would you prefer?
*
A Zoom / Google Meet conversation
A personal video submitted by email
Either option works for me
I would prefer to discuss and alternative arrangement
I would prefer a meeting without family members (family participation is optional)
If you would like to submit a video, a suggested length is 2-5 minutes. You may introduce yourself, share your journey, explain your financial needs, talk about your family, or describe your hopes for the future.
Browse Files
Drag and drop files here
Choose a file
Cancel
of
More Than Assistance: Building Lasting Connections
Participation in a meeting or video submission is an opportunity for us to better understand your circumstances, hear your story, and get to know you and your family on a more personal level. At All For Dave Foundation, we hope to do more than provide financial assistance - we want to build lasting relationships with the individuals and families we support. Our goal is to become part of your extended support system, stay connected throughout your journey, celebrate milestones with you, and continue offering encouragement as you navigate life beyond this moment. Inspired by Dave’s spirit of service above self, we believe that helping someone is not a one-time act, but the beginning of a meaningful connection. We hope that every family we support feels welcomed, valued, and part of the All For Dave family long after assistance has been provided. Neither a meeting nor a video submission guarantees financial assistance, and applicants will not be judged based on presentation skills, confidence, or how emotionally they share their story. Any ongoing relationship or communication with the Foundation will always respect your comfort, privacy, and boundaries. Your story will never be shared publicly without your separate, explicit consent.
Back
Next
Applicant Certification and Signature
I certify that the information provided in this application is true and complete to the best of my knowledge. I understand that the Foundation may request additional documentation relevant to my application, and that submitting an application does not guarantee financial assistance. Decisions are subject to eligibility criteria, and available funding. I understand that I can ask questions about how my information will be used and that public use of my story or image requires separate consent.
Applicants Full Name:
*
First Name
Last Name
Applicants signature:
*
Todays Date:
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
If completing this application for another person, your name and relationship:
Submit
Submit
Should be Empty: