for Emergency Funding
treatment status: (circle one)
Active- treatment for recurrent cancer
Active- stem cell/ bone marrow transplant
attach a letter verifying your child's treatment status. (This
can be from a physician, social worker, Partners in Health
coordinator or visiting nurse.)
are you requesting the Lifeline consider for payment?
(please include copy of bill)
Have you had to stop working to care for your child at this
time? Yes No
If yes, please provide a copy of your most recent pay stub
as proof of prior
of person filling out application______________________________
mail completed application to:
Childhood Cancer Lifeline of NH
Attn: Emergency Fund
Hillsboro, NH 03244
The Lifeline considers these requests at their monthly Board
of Director's meetings.
Applications with missing information will not be considered.
Emergency funding is only available to New Hampshire families.
The amounts allotted are at the discretion of the Board of
Directors. Availability of funding, as well as access to other
supports will be factors in the determination. All decisions