DeSoto Hope Community Cancer Support

2026 Grant Application for Travel

Date:_________________________

Patient Name:____________________________

Address:                                                     City: _________________

State: MS   Zip Code:_____________Phone:____________________

Date of Birth:_______________ Age:_____

Email Address:_______________________

Date first diagnosed with cancer:__________________

Type of Cancer:______________________ Is this cancer a recurrence?_______ Date of reccurence______________

Name of Local Oncologist: ___________________________________

Local Oncologist’s Phone Number:_____________________________

When will you be traveling? __________________________________

Location Traveling To:_____________________________________

Contact Information: _____________________________________

Appointment Date:_______________________________________

DeSoto Hope Travel Grants cannot accept applications from people living outside of DeSoto County. If approved, we give a one time $500 grant to cancer patients wanting to travel outside of the mid-south for a second opinion or treatment. Please know that we will need verification of an appointment before the grant will be given.

To begin approval process please email application to: Tracy Gallagher Email: desotohope@gmail.com Phone: (901) 857-4258

Signature:___________________________________________

Date:___________________________________

For Office Use:

Date Board Approved:_______ Check No:_______ Date Mailed: ____________