SHORT APPLICATION FOR FINANCIAL ASSISTANCE

One of the objectives of The Miles 4 Matthew Foundation is to financially assist deserving families of kids battling cancer. The organization provides grants to minimize the financial hardships that are directly attributable to the child’s illness. 


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Email *
Child’s Name *

(Information will be used for statistical purposes only and will not affect eligibility.)

Date of Birth
 *
MM
/
DD
/
YYYY
Gender
(Information will be used for statistical purposes only and will not affect eligibility.)
Ethnicity:
(Information will be used for statistical purposes only and will not affect eligibility.)
Clear selection
Parent/Legal Guardian Name:
Address:
City:
State:
Zip Code:
Phone:
Cell Phone:
Email Address:
Preferred Method of Contact:
Clear selection
Requested Grant Amount ($ amount required):
*
Intended use of grant (if applicable, please provide bills paid directly to the vendor with the vendor name, account number, mailing address, family’s last name, and dollar amount owed):
*
*Parent/Legal Guardian’s Signature:
 *
By signing this application, you agree to allow The Miles 4 Matthew Foundation to publish your family's name and your child’s medical condition or cancer diagnosis. Additionally, you authorize your Social Worker, Medical Professionals, and The Miles 4 Matthew Foundation to share basic medical information regarding your child’s case with each other.
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