We’re here for you.

To apply for a grant from the Collin Cares Cure Cancer Foundation, please complete the online application below.

Personal Information

Name

First Name

Last Name

Age

Guardian Name (if under 18)

First Name

Last Name

Phone

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Referred by (optional)

Medical Information

Name of Physician or Oncologist

First Name

Last Name

The facility where you are being treated

Social Worker Name (if applicable)

First Name

Last Name

Social Worker Facility (if applicable)

Social Worker Phone (if applicable)

(###)

###

####

Your Story

To allow the Collin Cares Cure Cancer review board the chance to know you as an individual, please answer the following to the best of your ability: In roughly 500 words or less, tell us about your life leading up to your illness and how your diagnosis has affected you and your family.

Please read and sign below: I understand and agree that no promises or assurances have been made to me or a party acting on my behalf by any representative of the Collin Cares Cure Cancer Foundation. The Foundation agrees that all medical information will remain confidential, and any reports written about this process will not use the applicant’s name or information without their permission. I understand and agree that there is a limit to the number of services or the grant I may receive. Typing my name below serves as my electronic signature.

First Name

Last Name

Witness (typing name below serves as electronic signature)

First Name

Last Name