Application for Emergency Funding


Name of child______________________

Current treatment status: (circle one)

Active- initial treatment
Active- treatment for recurrent cancer
Active- stem cell/ bone marrow transplant

Please attach a letter verifying your child's treatment status. (This can be from a physician, social worker, Partners in Health coordinator or visiting nurse.)

What bill are you requesting the Lifeline consider for payment?
(please include copy of bill)
Amount requested:____________

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

Signature of person filling out application______________________________

Please mail completed application to:

Childhood Cancer Lifeline of NH
Attn: Emergency Fund
PO Box 395
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 are final.