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Request For Assistance Application
The Zachary Cole Foundation is here to support a wide range of needs for young adult athletes battling B-ALL Negative Leukemia and their supportive family members.
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* Indicates required question
First Name (diagnosed with B-ALL Negative
Leukemia
)
*
Your answer
Last Name
(diagnosed with B-ALL Negative
Leukemia
)
*
Your answer
Age
*
Your answer
Date of Diagnosis
*
MM
/
DD
/
YYYY
Name & Address of Patient’s Treatment Facility
*
Your answer
Name & Address of Patient’s Oncologist
*
Your answer
Current Living Address of Family
*
Your answer
Phone
*
Your answer
Email
*
Your answer
TYPE OF ASSISTANCE NEEDED
*
Personal Needs
Financial
Transportation
Other:
Required
Brief Description of Request
*
Your answer
Date Funding is Needed
*
MM
/
DD
/
YYYY
Supporting Documents (if applicable)
Medical Records
Financial Statements
Referral Letter
Other:
Have you received assistance from the Zachary Cole Foundation before?
*
Yes
No
Required
If yes, please provide details
Your answer
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