Bear Fund Application | Cancer Support Community

Fund Eligibility

Are you a staff member of Children's Hospital of Los Angeles, Cincinnati Children's Hospital Medical Center, Phoenix Children’s Hospital, Anschutz The Children's Hospital of Colorado, or the Cancer Support Community Affiliate Network Program? If no, please stop here and ask your health care team to apply on your behalf.

Yes

Has the family already been referred to one of our affiliates?

Yes

Please select the affiliate below

Cancer Support Community Greater Cincinnati/Northern Kentucky

Cancer Support Community Los Angeles Affiliate

Cancer Support Community Arizona

Eligible applicants must meet specific annual income guidelines. Grant applicants cannot exceed 300% of U.S. Federal Poverty Guidelines.

Please select the best description of your household:

1 person household and income up to $45,180 per year

2 person household and income up to $61,320 per year

3 person household and income up to $77,460 per year

4 person household and income up to $93,600 per year

5 person household and income up to $109,740 per year

6 person household and income up to $125,880 per year

7 person household and income up to $142,020 per year

8 person household and income up to $158,160 per year

For each additional family member, $16,140 per year

Does your patient’s parent/guardian meet the eligibility requirements shown above? If no, please stop here. They are not eligible for a grant at this time.

Yes

Please enter in the estimated annual income. This information will help us guide this program.

Patient Information

Patient’s First Name

Patient’s Last Name

Parent/Guardian First Name

Parent/Guardian Last Name

Patient’s Date of Birth

Family is Spanish speaking/writing/reading

Cancer Type

Date of Cancer Diagnosis

Please specify if the patient is in:

Active treatment (chemo, radiation, surgery, etc.)

Survivorship follow-up

Palliative or hospice care

Other

Gender

Primary Race

Asian Subcategory

Other Pacific Islander Subcategory

Secondary Race

Asian Subcategory

Other Pacific Islander Subcategory

Ethnicity

Family requires language translation support

Required language

Mailing Address for Fund Distribution

Address

Address 2

City

State

ZIP Code

Phone Number

Would the patient’s parent/guardian like a referral to the CSC Pediatric Oncology Navigation Services?

Yes

Indicate if CSC has permission to refer family to support services to one of our affiliates (if not referred). This includes affiliate reaching out to family to offer programs and services. If so, select one of the choices below

Cancer Support Community Greater Cincinnati/Northern Kentucky

Cancer Support Community Los Angeles

Cancer Support Community Arizona (Phoenix)

Anschutz The Children's Hospital of Colorado

Prefer no contact

Indicate the treatment center where the patient is being treated

Cincinnati Children’s Hospital

Children’s Hospital of Los Angeles

Phoenix Children's Hospital

Anschutz The Children's Hospital of Colorado

Name and Relation of Person Completing the Application

Name of Referring Professional

Specify the type of health care professional

Social Worker

Nurse

Navigator

Physician

Affiliate Team Member

Other (please specify)

Contact Information for Referring Professional

Phone

Financial Needs Applicant Agreement

Do you attest that the information you've provided on this form is accurate?

I attest

I do not attest

Does the parent and/or guardian agree to be contacted by the Bear Fund for the purpose of learning more about their cancer story and/or the Bear Fund’s impact on their child’s cancer?

Yes

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