Apply For Assistance

Courage Under Cancer Foundation

Cancer Patient Assistance – Apply Now

The Courage Under Cancer Foundation exists to provide financial help to those battling cancer. If you are in a situation where you have to choose between treatment or paying a bill, complete our cancer patient assistance application form. Complete it online or download our form and submit via email at assistance@courageundercancer.org.

How We Help

We offer up to $1,000 maximum assistance to each applicant. Any financial assistance we provide will be payable to an organization, lender, or a company, not to the applicant personally. We can help with utility bills, rent/mortgage payments, medical bills, medication, travel expenses for doctor visits, car expenses – check out our Who We Help page for more details.

Assistance Application Form

Please complete all fields and attach any necessary documentation and press submit. Alternatively, you can download a printable form, print, scan, and submit it by email to: assistance@courageundercancer.org

Tell us about who you are and where you live
Applicant Name*
First Last
Current Mailing Address*
Street Address Address Line 2 City State ZIP Code
Home Phone*
Cell Phone*
Email*
Date of Birth*
Please add your DOB without spaces e.g. MMDDYYYY
Is anyone applying on your behalf?*
- Yes
- No
Please provide name and phone number of person applying on your behalf.*
First Last
Phone Number*
How did you hear about us?
The following information is collected to be sure that everyone is served fairly without regard to race, color, or national origin. The information provided will not affect your eligibility or benefit amount.
Tell us what you need assistance with and why?
i.e. Utility bills, rent/mortgage, medical bills, medication, travel expenses for doctor visits, car payments.
Please upload a copy of the bills that you would like to be paid*
Drop files here or

Accepted file types: jpg, png, pdf, Max. file size: 512 MB.
What is your diagnosis?*
Please provide MRI Report, Pet Scan Report or Letter from Oncologist*
Drop files here or

Accepted file types: jpg, png, pdf, Max. file size: 512 MB.
Digital Signature*
- Applicant Acceptance of below:
I certify that above information along with any attachments are true and complete to the best of my knowledge. I understand that this application must be approved by the majority of the Board of Directors at C.U.C.F and that I (of the person that applied on my behalf) will be notified if approved. I fully understand that this is a one-time donation. I also understand that the donation will be payable to an organization, lender, or company not to me personally.
Applicant's Signature*
Please type your name
CAPTCHA
Email
This field is for validation purposes and should be left unchanged.

NEED HELP? EMAIL:

QUESTIONS? EMAIL:

Mailing Address:

Courage Under Cancer Foundation

Cancer Patient Assistance – Apply Now

How We Help

Assistance Application Form

Tell us about who you are and where you live

Mail Donations to :

Your Donation

Your Details & Billing Address

Payment Details