FAMILY ASSISTANCE REGISTRATION - MINOR

Live Life Even With Cancer – Family Support Program Application.

All information is confidential and used solely to determine eligibility for assistance.

APPLICANT INFORMATION

Parent/Guardian Name:

CHILD'S INFORMATION

HOUSEHOLD INFORMATION

SUPPORT REQUESTED

(Please check all that apply)

Hospital Social Worker / Case Manager (if applicable)

Other Sources of Assistance

FOR OFFICE USE ONLY

DOCUMENTS REQUIRED

Please attach copies of the following:

• Proof of child’s diagnosis (doctor’s letter or treatment plan)

• Recent medical bill, therapy invoice, or related expense (if applicable)

• Photo ID of parent/guardian

• Proof of income (pay stub, SSI, or unemployment documentation)

• Medical or household bills related to assistance requested

CERTIFICATION & CONSENT

I certify that the information provided is accurate and truthful to the best of my knowledge. I authorize Live Life Even With Cancer to contact the treating hospital, physician, or social worker to verify treatment status and financial need. I understand that funds are limited and assistance is awarded based on availability and demonstrated need.