The Northern New England Clinical Oncology Society Cancer Community Support COVID Grocery/Gas Card Program is designed to support the emergency needs of patients with cancer in Northern New England. Practices/clinics without an affiliated non-profit organization/foundation to provide direct, emergency assistance to patients are eligible to apply for gift cards to distribute to patients on behalf of NNECOS. Recipients of the cards must be hematology/oncology patients under active treatment or receiving palliative care services as they approach hospice. Each site must identify a champion to take responsibility for program implementation, accountability and reporting. These cards ($25 each) are provided as a gift to patients from NNECOS.

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* 1. Applicant Contact Information:
Please list the site "champion" who will accept responsibility for this program.

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* 2. Approximately how many patients does your site/clinic serve each month?

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* 3. Describe the infrastructure your organization has in place to efficiently and accountably distribute cards to patients in need.

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* 4. Please specify the number of cards requested in each category and the vendor from whom you'd like the gift cards purchased. 
A maximum of 100 gift cards total will be awarded per eligible practice until funding is exhausted.

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* 5. Are you receiving funding from other charitable entities to support similar activities?

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* 6. How would this assistance integrate with other patient assistance efforts at your practice/clinic?

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

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* 8. How did you hear about this opportunity?

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* 9. Attestation: I attest that the information contained in this application is true and that I will ensure the gift cards are distributed for the intended purpose.

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* 10. Signature (enter initials)

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