Application For Assistance

We thank you for your interest in Tricia’s Hope.

Due to a large increase in applications for aid, we will be working on supporting as many patients as possible, but are currently prioritizing local (Indiana) recipients first before expanding outside our community.

Please complete this application and submit with written documentation of diagnosis.

Tricia’s Hope INC does not discriminate and awards grants to individuals in need based on available funds.

"*" indicates required fields

Name*

First Last

Address*

Street Address City State ZIP Code

Thank you for your interest

While we hope soon to be able to service and support cancer patients anywhere in the US, due to a large volume of requests we are prioritizing recipients in our own community and state (Indiana) before those outside.

We sincerely hope to be able to expand soon, and should things change, we will be sure to update you then.

Thank you and we wish you good health.

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Indiana

Form submission is reserved for Indiana Residents

Date of Birth*

Phone*

Email*

Diagnosis*

I will provide written documentation of diagnosis by:*

Upload

Mail

Written documentation of diagnosis is required; applications are considered incomplete until documentation has been received. You can upload or mail documentation.

Mail Documentation of Diagnosis to: Tricia's Hope
4209 SR 43 N
West Lafayette, IN 47906

Date of Diagnosis*

Upload Documentation of Diagnosis*

Drop files here or

Max. file size: 20 MB.

You can submit multiple files; files upload directly and securely to our DropBox account.

Current Cancer Treatment Plan*

Number of Individuals Residing in Your Household*

Please enter a number from 0 to 15.

Annual Household Income*

Household Debt*

Monthly Expenses*

Please be as detailed as possible; all answers will remain confidential.

In what areas do you need help?*

Emotional Support

Spiritual Support

Financial Support

What would you use financial assistance for at this time?*

Would you be willing to help us spread the word as a goodwill ambassador for Tricia’s Hope?*

Yes

No

How did you hear about Tricia's Hope?*

Name of Person Completing this Form*

First Last

Signature*

Name

This field is for validation purposes and should be left unchanged.