Ellis Fund: Application for Assistance
Please fill out the form below. Ellis Fund usually contacts applicants within one week of receiving an application, if not before.

By submitting this form, you are agreeing that the Community Foundation of the Ozarks can receive information by verifying your child's cancer status. You hereby certify that your child has been diagnosed with cancer and that your family requires financial assistance. You also certify that the information provided here is true and correct. All information is considered confidential and will be used only for eligibility determination. You may be asked to discuss benefits of assistance.

As a reminder, the Ellis Fund offers assistance only to families residing in Southwest Missouri who have a child (18 or younger) who has been diagnosed with cancer. We prioritize families who live in Missouri's Greene, Barry, Christian, Stone, and Taney counties, with additional consideration given to those in the other counties surrounding Springfield, Missouri.
Email address *
Parent/Guardian name *
Your answer
Parent/Guardian phone *
Your answer
What county do you live in? *
Your answer
Patient name *
Your answer
Patient date of birth *
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Mailing address *
Your answer
How many children are living at home, and what are their ages? *
Your answer
Do you have any other dependents? If so, please describe.
Your answer
Patient's medical diagnosis *
Your answer
Name of patient's physician/oncologist *
Your answer
Physician/oncologist phone number *
Your answer
Physician/oncologist fax number
Your answer
How much financial assistance are you requesting from The Ellis Fund? *
Your answer
Please describe the intended use for the requested funds. *
Your answer
Please name other agencies from which you are currently receiving funds. *
Your answer
What kinds of assistance/services are being provided to you and your child? *
Your answer
Parent employer (please list employer for both parents, if applicable) *
Your answer
Do you have health insurance? *
If you have health insurance, who is your provider? *
Your answer
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