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PROGRAM GUIDELINES

1. Families living in Southeastern WI/Northern IL affected by cancer, with children under the age of 18 in the same primary residence. Additionally, one or more of the following qualifications must be met in order to be considered:

· a) Child is a cancer patient, where the child has received cancer treatment within the current calendar year. Treatment is defined as any chemotherapy (including maintenance), surgery, transplant etc. A child can be in remission and still receive treatment. However, children who see their oncologist for regular follow-up tests do not qualify for the program, if they have not had any other treatment like those listed above within the calendar year.

· b) Parent is a cancer patient, where the parent has received cancer treatment within the current calendar year. (see above for treatment examples). The family is facing financial hardship due to said treatment(s). *Although the application does not require written proof, there is a box that asks to describe why assistance is needed.

· c) Sibling or parent has passed away from cancer within the current calendar year.

2. All children (under age 18) whose primary residence is that of the selected household are eligible to be gifted through the program.

3. Families must be matched with an Angel donor in order to participate in the program - we will do our best to find Angels for every family.

4. Financial hardship assessments are based on applicants' written summaries. No financial documentation is required.

5. Families must be residents of Southeastern WI/Northern IL.

6. All information (Application along with Needs & Wishes Lists) must be submitted to apply.

Families who have children that meet the criteria above should complete an application below. Once approved, email notification will be sent along with a request to complete a Needs & Wishes List for each child under the age of 18 in the family. *Completion of this application does not guarantee that you will be selected as an Angels of Hope Gift Recipient Family

APPLICATION

* Indicates required field

Full Name *

First

Last

Address *

Line 1

Line 2

City

State

Zip Code

Country

Phone Number *

Email *

Are you the cancer patient? *

Yes No

IF YES, YOU ARE THE CANCER PATIENT, PLEASE ENTER YOUR INFO BELOW:

IF NO, PLEASE ENTER CANCER PATIENT'S INFO BELOW:

Birthdate (MM/DD/YYYY) *

PATIENT'S NAME *

DATE OF DIAGNOSIS (MM/DD/YYYY) *

BIRTHDATE (MM/DD/YYYY) *

DIAGNOSIS *

DATE OF DIAGNOSIS (MM/DD/YYYY) *

TYPE(S) OF TREATMENT RECEIVED THIS CALENDAR YEAR *

LAST TREATMENT DATE (MM/DD/YYYY) *

HEALTHCARE PROVIDER *

CLINIC/HOSPITAL *

YOUR CURRENT TREATMENT STATUS *

Active Treatment Follow-Up Remission

DIAGNOSIS *

TYPE(S) OF TREATMENT RECEIVED THIS CALENDAR YEAR *

LAST TREATMENT DATE (MM/DD/YYYY) *

HEALTHCARE PROVIDER *

CLINIC/HOSPITAL *

CANCER PATIENT'S CURRENT TREATMENT STATUS *

Active Treatment Follow-Up Remission

IF DECEASED, PLEASE LIST DATE OF PASSING (MM/DD/YYYY) *

HARDSHIP STATEMENT

PLEASE INDICATE HOW THE FAMILY HAS BEEN AFFECTED FINANCIALLY BY CANCER AND HOW THEY WOULD BENEFIT FROM BEING APPROVED FOR THIS PROGRAM: *

CHILDREN'S INFORMATION

NAME(S) & AGE(S) OF CHILD(REN) UNDER AGE OF 18 RESIDING IN SAME HOUSEHOLD

CHILD #1

CHILD'S NAME: *

CHILD'S AGE: *

CHILD'S GENDER: *

CHILD #2

CHILD'S NAME: *

CHILD'S AGE: *

CHILD'S GENDER: *

CHILD #3

CHILD'S NAME: *

CHILD'S AGE: *

CHILD'S GENDER: *

CHILD #4

CHILD'S NAME *

CHILD'S AGE: *

CHILD'S GENDER: *

CHILD #5

CHILD'S NAME: *

CHILD'S AGE: *

CHILD'S GENDER: *

SUBMIT APPLICATION

The Angels of Hope selection process is based on diagnosis and need as described by the applicant. Therefore, no reporting of financial income or financial documentation is required from families. Angels of Hope is a first come, first served program based on the date your Application is received. However, we reserve the right to reject applications that do not meet the program requirements.

Completion of this Application does not guarantee that you will be selected as an Angels of Hope Gift Recipient Family. You will be contacted regarding the status of your application within five (5) business days.

If you have specific questions, feel free to contact Lisa Jenewein at (262) 909-9294, LisaJenewein@yahoo.com or Susan Jenewein at (262) 515-6987, susieqcupcake@att.net.

By clicking Submit, you understand and acknowledge receipt of the information listed above. As an applicant in the Angels of Hope holiday gift-giving program, I, for myself, my executor, administrators, and assigns do hereby release and discharge the American Cancer Society, Relay For Life of Kenosha, the event site, their management, their officers, members, sponsors, organizers, volunteers or their representatives, or their successors, and all cooperating businesses and organizations from all claims of damages, demands, actions, and causes whatsoever, in any manner arising or growing out of my participation in this program.

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