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Apply for Assistance

(pediatric cancer patients & families)

What is your name*

What is your email address?*

What is your phone number?*

Your City?*

What is your relationship to the potential beneficiary?**

How much (dollar amount) assistance is being requested? *

Are you a Go 4 The Bell volunteer?*

Yes

What is the potential beneficiary’s name? *

What is the illness or reason for applying? (Short answer. The full story can be given next.) *

Tell us the potential beneficiary’s story. *

What is the telephone number for the potential beneficiary family? *

What is the email address for the potential beneficiary family?*

What is the potential beneficiary’s current city?*

Where has the potential beneficiary lived, primarily? (City)*

If applicable, what is the link for the potential beneficiary family’s FaceBook Page? *

What is the potential beneficiary’s birthdate?*

Does the potential beneficiary family have other children?*

Yes

If yes, list their ages. If none, type N/A*

Are the parent(s) of the potential beneficiary employed? *

Yes

If yes, mother’s employer? If no, type N/A*

If yes, father’s employer? If no, type N/A*

What is the potential beneficiary’s church name?*

Is the potential beneficiary a Go 4 The Bell volunteer?*

Yes

What civic groups or organizations is the potential beneficiary’s family active with?*

Does the potential beneficiary have health insurance?*

Yes

Does the potential beneficiary have life insurance?*

Yes

Are any benefits being planned or have any benefits been conducted already? *

Yes

What are the benefits conducted or planned?*

Are there currently any GoFundMe campaigns associated with the potential beneficiary? *

Yes

If there are any GoFundMe campaigns associated, please provide link or links here: *

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