2024 Survivor Grant Application

L.I.F.E. is a 501(c)(3) non-profit organization dedicated to cancer survivorship by providing assistance to young adults who are fighting cancer and in financial need. This is accomplished through our cancer survivor grant program.  The amount of each grant depends on the availability of funds and resources, but is approximately $1,000.  Since 2003, we have proudly awarded over $250,000 towards financial assistance and research.

This L.I.F.E. Survivor Grant application will be open from March 19, 2024 (the first day of Spring) through July 1, 2024.  Recipients will be announced on July 17, 2024 (Eric’s birthday). All candidates must meet the following criteria, and be able to provide the information below.  If you are unsure about something, please contact us with any specific questions.

  • The applicant must be between the ages of 18 and 30 years old.
  • The applicant must be a U.S. citizen and have received treatment in the U.S.
  • The applicant must be in a state of financial need having either lost their job, experienced sustained major wage losses, or have limited employment opportunities.
  • The applicant should be able to explain how their cancer has affected their current financial situation.
  • The applicant must complete a Medical History Verification Form that has been signed by a licensed practitioner by whom you were treated.
  • The applicant must agree to sign our Photo and Consent Release Form and and email it back to us at life@givetolife.org. If an applicant is selected for one of our grants, we do ask that they agree to have their name, photo, and a brief story published onto our website and/or social media. The ability to tell their story helps us fundraise for future patients and keep our mission alive.

L.I.F.E. will uphold the privacy of each applicant, but we do ask that if an applicant is selected for the grant, that they also agree to have their name, photo, and brief story published onto our website and/or social media.  All other information gathered through our application process is kept secure and confidential.

    Applicant Information

    Applicant’s Full Name

    Applicant’s Phone #

    Applicant’s Email

    Applicant’s Birthdate

    Applicant’s Street Address

    City

    State

    ZIP

    Is the Applicant 18 – 30 yrs old?

    YesNo

    Applicant Gender

    MaleFemale

    Applicant’s T-shirt size

    XSSMLXLXXL

    Photo Consent and Release

    To process this application, the applicant must agree to and sign this Photo and Consent Release Form. This will need to be printed, and then either scanned or take a photo, and then upload using the button below.

    Please upload a photo of the applicant (20mb max)

    Diagnosis and Treatment

    To process this application, a Medical History Verification Form must be filled out and signed by a licensed practitioner by whom they were treated. This will need to be printed, and then either scanned or take a photo, and then upload using the button below.

    Is the applicant’s diagnosis confirmed?

    YesNo

    Diagnosis and Stage

    Is the applicant currently receiving treatment?

    YesNo

    Diagnosis Date

    Date of the applicant’s last treatment?

    What was last type of treatment that the applicant received?

    SurgeryRadiation TherapyChemotherapyImmunotherapyTargeted TherapyHormone TherapyStem Cell TransplantPrecision MedicineOtherUnknownNone

    What was the intent of the treatment that the applicant last received?

    AdjuvantNeoadjuvantInductionConsolidationMaintenanceFirst lineSecond linePalliativeOtherUnknown

    Please let us know any other information related to the applicant’s diagnosis and/or treatment you wish to share.

    Hospital and Physician Information

    Hospital or Treatment Facility Location

    Applicant’s Physician

    Physician’s Phone #

    Financial Information

    Is the applicant in a state of financial need having either lost their job, experienced sustained major wage losses, or have limited employment opportunities?

    YesNo

    Please describe how cancer has affected the applicant’s current financial situation

    Are there any specific financial requests that the applicant requires assistance with?

    Does the applicant have health insurance?

    YesNo

    Is the applicant currently employed?

    YesNo

    If yes, please provide the name of the current employer

    If yes, please provide the applicant’s job title

    Referral Information

    Referred By

    Referring Person’s Hospital/Org

    Referring Person’s Phone #

    Referring Person’s Email

    Relationship to Applicant

    MyselfSocial WorkerNursePhysicianMedical CaregiverOther

    How did you hear about L.I.F.E.?

    FriendGoogle SearchSocial WorkerNursePhysicianMedical CaregiverOther