Project Be the Light (PBTL) Application (BCH Foundation)
This is an application form to request financial assistance for families experiencing a cancer diagnosis from Project Be the Light/BCH Foundation. The family applying/receiving funds must live within Boone County, Iowa. All funds awarded will be paid directly to the entity - for example to the medical facility, electric company, and so on. Requests for each payment must be submitted to BCH Foundation. Once received, BCHF will reply with questions/clarifications within 5 business days. Awards will be made within 10 business days from receiving the application. Thank you.  
Sign in to Google to save your progress. Learn more
Email *
Applicant's Full Name *
Address, City, State, Zip *
Email and mobile number *
Birthdate *
MM
/
DD
/
YYYY
Marital status *
Dependents: 
Name / Age / Relationship
 *
Employer and Occupation *
Do you rent / own / live with family or friends? *
Are you covered by any health insurance plans? *
Who is the carrier of the plan? *
Please list insurance carrier and policy number *
Physician involved in care *
Please share the type of cancer being treated *
Please provide a statement of your need and how this financial assistance will help. (Any financial burdens or debts related. Specific needs your family is facing. How receiving assistance from PBTL will benefit your family during this time.) *
Would you be willing to share your story with others when the time is right, to raise awareness about cancer and support needed for families facing similar challenges? 
 *
I certify that all information provided in this application is true, complete, and accurate to the best of my knowledge. I understand that providing false or misleading information may result in disqualification from receiving assistance. 

By signing below, I agree to the terms and conditions outlined in this application and consent to the verification of the information provided. I further acknowledge that my electronic signature has the same legal effect as a handwritten signature.

Consent for PBTL/BCH Foundation to contact you for further information or clarification, if needed. 

Agreement to comply with terms and conditions associated with receiving assistance from PBTL. 

Print Name and Date below:
 *
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. - Terms of Service - Privacy Policy

Does this form look suspicious? Report

Google Forms