Super Jake Super Hero Grant Program

Currently, this program is limited to children diagnosed with neuroblastoma who reside in Illinois or Wisconsin or who are treated for neuroblastoma at a children’s hospital in Illinois or Wisconsin. This includes children with an original diagnosis as well as children who have relapsed with neuroblastoma.

The mission of The Super Jake Foundation is to help children with neuroblastoma and their families. We know that having to complete a cumbersome application process and attach income tax returns and other documentation is stressful and time consuming. All we ask is that you complete the one-page application below, stating the need or dream you would like this grant to help you fulfill. We need you to include a photo of the patient. We also ask the social worker and/or oncologist to provide a signed letter on the hospital letterhead to confirm the diagnosis for neuroblastoma, including any other disease specific information they would like to include. If your application is approved, we request that you keep us posted on your progress.

Patients Name *

First Name Last Name

Patients Age *

Date of Birth *

Date

Parents Names' *

First Name Last Name

Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Phone Number *

Area Code Phone Number

Email *

example@example.com

Date Of Diagnosis *

Date

Hospital Name *

Oncologist Name *

Oncologist Phone *

Area Code Phone Number

Oncologist Email *

example@example.com

Social Worker Name *

Social Worker Email *

example@example.com

Social Worker Phone *

Area Code Phone Number

Patients Story *

Tell us about you: What was your life before you were diagnosed? What is it like now?

Need Statement *

What is the need or dream a Super Jake Grant could help you fulfill?

Requested Grant Amount *

Attach a Photo of the patient before and after his/her diagnosis *

Browse Files

Attach a letter on hospital letterhead verifying the patients diagnosis SIGNED by the treating oncologist and/or hospital /social worker *

Browse Files

Do you have a Journey page on Facebook or a Blog page? If so please include a link

If your grant application is approved, The Super Jake Foundation asks that you email or mail an updated photo, as well as a letter/email updating us on your treatment and telling us how the grant monies were used. Please provide this update within 3 months of receiving your grant award.

The Super Jake Foundation may also follow-up with you via email every once in awhile to get an update.

The Super Jake Foundation holds the right to use the patient and family’s first names and last name initial, story, and pictures to help raise awareness for The Super Jake Foundation, and to increase awareness of neuroblastoma and pediatric cancer and the need for funding for an unlimited period of time.

Parent Signature *

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