Megan's Wings Gas Assistance Application

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Our Gas Assistance Program is meant to help pediatric and young adult patients get to treatment when high gas prices, distance/frequency of appointments and lost income have created financial hardship making it difficult to get to treatment. A medical social worker of a child in active treatment for cancer can submit an application. Patients qualify if the meet the guidelines listed here:

1. Patient must receive treatment at a Southern California Hospital.
2. Patient must travels 20 or more miles (one way) 4 or more times per month for appointments or
3. Patient must travels 45 miles or more (one way) 2x/mo for appointments.
4. Patient lives close, but family must travels 3 or more times weekly for treatment such as radiation, proton therapy, transplant or daily hospital visits.

Applications are reviewed weekly and approval is based on need and funding availability. If approved, gas cards will be mailed directly to the family home along with an approval letter. We will email the social worker what level of support the family will receive. For questions, please call or email us at (909) 532-8135 or support@meganswings.org.

Email *

1. Briefly explain why the family is experiencing financial hardship due to the child's illness & needs help with gas:

2. Is the child in active treatment for cancer? *

Yes

3. How many times a month on average does the child go in for treatment? *

4. How many miles does the family travel one way to treatment?

5. What is their car's average miles/gallon? (if unsure use 22 miles/gallon)

6. Has the cost of gas affected the family's ability to get their child to treatment on a regular basis?

Yes

Sometimes

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Patient's Race or Ethnicity

White or Caucasian

Hispanic or Latino

Black or African American

Asian

Native Hawaiian or Pacific Islander

American Indian or Alaska Native

Two or More Races

Other

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8. Has gas cost affected the family's ability to pay other bills?

Yes

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9. Has one or both parents lost income due to their child's cancer treatment and care?

25% household lost income

50% household lost income

75% household lost income

100% lost income (i.e: single breadwinner had to leave work to care for child or both parents are unable to work)

None (i.e: child's caretaker was not working before diagnosis or has flexible work hrs, etc)

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