What We Fund

Cancer Relief Fund

Providing temporary financial support to cancer patients needing assistance with cancer treatment-related costs. Its mission is to ease the suffering of cancer patients by providing for their immediate needs in ways not provided for by other programs.

Cancer Relief Fund Application:

Please fill out this form as accurately as possible and attach any bills, invoices, or receipts for the items for which assistance is being requested. If the request is over $100, additional paperwork may be required. Please keep in mind that the Cancer Relief Fund does not pay for credit cards, non-essential phone charges, or loans and does not reimburse bills that have already been paid.

Patient name*

Patient phone*

Patient address*

Physician name*

Office name*

Requester name*

Requester phone*

Requester's email*

Describe the patient’s need (please check all that apply)*

Assistive device (e.g. wheelchair)

Meals or nutritional supplements

Transportation

Wig ($100 maximum reimbursement)

Gift card (gas)

Gift card (groceries)

Other

Please give a brief description of patient’s current circumstances.*

Amount requested*

Does the patient have a cancer diagnosis or related disorder?*

Yes

Have other resources been researched and contacted?*

Yes

Has the patient received a previous grant from the NCMF Cancer Relief Fund?*

Yes

File upload:

Please attach any bills, invoices or receipts for the items for which assistance is being requested. I authorize the release of this information to the NCMF Cancer Relief Fund Committee and its representatives.

Signature*

Date*

(330) 433-1411

6046 Whipple Ave NW, North Canton, OH 44720

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