Cancer Community Support Emergency Need Grant Application Survey

The Northern New England Clinical Oncology Society Cancer Community Support Emergency Need Grants are designed to support the emergency needs of patients with cancer in Northern New England (Maine, New Hampshire, and Vermont) facing food insecurity and related financial toxicities. Grant funds are awarded directly to a 501(c)3 non-profit organization that has the infrastructure in place to provide much-needed emergency assistance to patients. Recipients must be hematology/oncology patients under active treatment or receiving palliative care services as they approach hospice. Funding awarded shall not apply to any per-patient annual assistance cap. The intent is for this grant to help as many patients as possible, with an average award target of $375, and a minimum of six patients helped per grant.

1.Applicant Contact Information:(Required.)

Name

Non-Profit Organization Name

Address

Address 2

City/Town

State

ZIP Code

Email Address

Phone Number

2.Grant amount requested ($3,000 max)(Required.)

3.How will the grant funds be utilized?
Describe the type of activities these funds will support.(Required.)

4.Describe the infrastructure your organization has in place to efficiently and accountably disburse funds to patients.(Required.)

5.Please provide examples of patient needs your organization funds.(Required.)

6.What is the average amount awarded per patient.(Required.)

7.Are you receiving funding from other charitable entities to support similar activities?(Required.)

Yes

8.How would this assistance integrate with other patient assistance efforts of your non-profit organization/foundation?(Required.)

9.Is there anything else you would like to share with the committee that will assist in evaluating your application?

10.How did you hear about this opportunity?

11.Attestation: I attest that the information contained in this application is true.(Required.)

Yes

12.Signature (enter initials)(Required.)