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Apply for Funding from CHAMP
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Name
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Email
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Address
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Phone number
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What type of cancer are you experiencing?
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What is your gender, age and marital status?
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Please tell us your story. What stage is your cancer and what side effects or personal/financial hardships are you experiencing from your cancer treatment? How has all of this affected your daily life? Also, please tell us how you heard about CHAMP.
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Have you received any other forms of financial assistance for cancer side effects?
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Which funding option would offer your family the most relief?
$500 in gas cards
Up to $1000 in financial assistance in your area of most need
Assistance with access to cannabis for symptom relief- up to $500
A combination of these options totaling no more than $1000
Groceries and/or essential items delivered through SHIPT ( can be in combo with other options to total no more than $1000
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Is there any additional information you would like to share? PLEASE INCLUDE THE NAME OF YOUR ONCOLOGIST and the name of the HOSPITAL where you're receiving treatment.
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Please tell us how your heard about CHAMP!
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