Financial Assistance Request for Pediatric Oncology Families

Contact Name

Please enter your full name.

This field is required.

Email Address

Please enter a valid email address.

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Mailing Address

Please provide your complete mailing address.

Address Line 1

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Address Line 2

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City

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State

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Postal Code

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Country

Phone Number

Please enter a valid phone number.

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How many in the family

Enter the number of family members.

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Diagnosis Description

Please provide details of the diagnosis.

This field is required.

Oncologist Name

Please provide the name of your oncologist.

This field is required.

Treatment Hospital

Please provide the name of the treatment hospital.

This field is required.

What you are requesting assistance for

Please describe what you need assistance with.

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Assistance Amount

Please specify the amount requested for assistance.

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Social Worker (optional)

If applicable, please provide the name of your social worker.

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Additional Details (optional)

Any other information you wish to provide.

Authority and accuracy

I certify that I am at least 18 years old and am the patient, the patient’s parent or legal guardian, or otherwise legally authorized to submit this request. I certify that the information provided is true and complete to the best of my knowledge.

This field is required.

Privacy and application processing

I have read and agree to the Privacy Notice – https://lightyourcandle.org/privacy-policy I consent to Pediatric Oncology Family Fund collecting, using, securely storing, and sharing the information in this application with its authorized staff, reviewers, service providers, and funding partners only as reasonably necessary to evaluate, verify, and administer my request.

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Verification and program terms

I authorize Pediatric Oncology Family Fund to contact me and the oncologist, treatment hospital, or social worker identified in this application to request verification of the information provided. I understand that submitting an application does not guarantee assistance and that funding decisions are subject to eligibility, available funds, and program discretion.

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Text and email updates

I agree to receive application-related emails and text messages at the contact information provided. Message and data rates may apply. Message frequency varies. Reply STOP to stop text messages. Consent is not a condition of receiving assistance.

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