Helping Hands & Hopeful Hearts

Do you know a cancer patient and/or caregiver that could use a little helping hand?

Nominate someone on their cancer journey who could benefit from items such as:

Fuel gift card
Grocery gift card

Meal train donation
Chemotherapy comfort bag
Port access clothing / head beanies

Fulfilling items of need on a gift registry/Amazon wish list
Completion of treatment celebration gift
Raffle basket request for a cancer charity/family fundraising event
Nursing staff or care team recognition request
Other opportunities where we can be of assistance

Our Angels would be honored to extend a helping hand in order to bring a little hope to your loved one's heart!

Our Angels deliver more than just gifts-they provide hope, support & cheer all year long!

NOMINATION FORM

* Indicates required field

YOUR Full Name *

First

Last

YOUR Address *

Line 1

Line 2

City

State

Zip Code

Country

YOUR Phone Number *

YOUR 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) *

DATE(S) & TYPE(S) OF TREATMENT RECEIVED or planning to receive *

LATEST TREATMENT DATE (MM/DD/YYYY) *

HEALTHCARE PROVIDER *

CLINIC/HOSPITAL *

YOUR CURRENT TREATMENT STATUS *

Active Treatment Follow-Up Remission

DIAGNOSIS *

DATE(S) & TYPE(S) OF TREATMENT RECEIVED or planning to receive *

LATEST 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: *

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 Helping Hands Recipient. 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, [email protected] or Susan Jenewein at (262) 515-6987, [email protected].

By clicking Submit, you understand and acknowledge receipt of the information listed above. As an applicant in the Angels of Hope Helping Hands program, I, for myself, my executor, administrators, and assigns do hereby release and discharge Angels of Hope, 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.

Submit

Helping Hands​for​Hopeful Hearts

Helping Hands
for
Hopeful Hearts