Application Information
Diagnosis and Treatment
Hospital and Physician Information
Financial Information
Photo Consent and Release
Referral Information
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Applicant's Full Name
Applicant's Phone #
Applicant's Email
Applicant's Birthdate
Is the Applicant 18 - 30 yrs old?YesNo
Applicant GenderMaleFemale
Applicant's T-shirt sizeXSSMLXLXXL
Applicant's Street Address
City
State Must be a resident in the state of Wisconsin. This is new for 2026. For the past number of years, donations have come exclusively from the state of Wisconsin, and the number of applications we have received exceeded the number of people we’ve been able to help. WI
ZIP
0%
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. (5mb max)
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.
20%
Hospital or Treatment Facility Location
Applicant's Physician
Physician's Phone #
40%
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
60%
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. (5mb max)
Please upload a photo of the applicant (15mb max)
80%
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
100%
