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HOME
ABOUT
CONTACT
DONOR WALL
IMPACT STORIES
OUR TEAM
Cancer Patient Donation Application
First name
Last name
Email
Phone
Address
Type of Cancer
Date of Diagnosis
Current Treatment Status (In treatment / Remission / Clinical Trial / Other)
Cancer Treatment Facility / Hospital Name
Doctor or Oncologist’s Name
Are you currently employed?
Yes
No
Employer name (if employed)
Monthly household income (estimate okay)
Number of dependents in household
Current financial challenges caused by cancer
Medical bills
Insurance copays
Prescription costs
Travel for treatment
Childcare
Housing / utilities
Loss of income
Other
Assistance Requested
What financial assistance are you requesting?
Medical bills
Treatment-related travel costs
Childcare
Rent/Mortgage
Utilities
Groceries
Other needs
Amount requested (estimated)
Briefly share your story
May The Mauer Foundation privately contact your hospital to verify your condition?
Yes
No
Do you give permission for your story or image to be shared publicly for awareness, only if you are selected?
Yes
No
Yes but anonymous
I certify the information provided is true and accurate
*
Yes
Date
Month
Day
Year
Submit
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ABOUT
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DONOR WALL
IMPACT STORIES
OUR TEAM
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