Patient Care Fund Application

At Craig’s Cause Pancreatic Cancer Society, we understand that a pancreatic cancer diagnosis can bring not only physical and emotional challenges, but also financial strain for patients and their families. This financial grant program was created to help ease some of that burden by providing support to those who need it most.

Our goal is to ensure that patients can focus on their care and well-being without the added stress of financial hardship. Through this program, we aim to offer meaningful support during a difficult time and to stand alongside patients as they navigate their journey.

To be eligible for this financial grant, applicants must meet the following criteria:

- Must have a confirmed diagnosis of pancreatic cancer
- Must have been diagnosed within the past 5 years
- Must be a living individual (not an estate)
- Must have a household income below the poverty line or have experienced a significant change in income due to illness.

Please send an email to erin@craigscause.ca with the following:
Most recent CRA Notice of Assessment for all household members
Letter of diagnosis from someone on your care team (oncologist, social worker, surgeon, etc)

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1. Full Name (Required.)

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2. Date of Birth (MM/DD/YYYY) (Required.)

Date / Time

Date

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3. Home Address

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4. Email Address

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5. Phone Number (Required.)

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6. Gender

Female

Male

Non-Binary

Prefer Not to Say

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7. Marital Status (Required.)

Married

Divoced

Widowed

Single

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8. Are you currently working? (Required.)

Yes

Unable to work due to diagnosis

Retired

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9. Is your partner currently working? (if applicable).

Yes

Unable to work due to diagnosis

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10. Hospital/Cancer Centre you receive care from (Required.)

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11. Referrals Received (check all that apply) (Required.)

Medical Oncologist

HPB Surgeon

Dietician/Nutritionist

Radiation Oncologist

Social Worker

Counselling

Palliative Care

Pain Management

Other

Optional Questions

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12. Age at Diagnosis

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13. Race/Population Group

American Indian or Alaska Native

Asian or Asian American

Black or African American

Hispanic or Latino

Middle Eastern or North African

Native Hawaiian or other Pacific Islander

White

Another race

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14. Do you currently smoke?

Yes

Occasionally

Former Smoker

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15. Do you engage in regular physical activity/exercise (150 minutes of moderate-intensity or 75 minutes of vigorous-intensity aerobic exercise per week)?

Yes

Sometimes

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16. Has a first-degree relative (parent, sibling, child) been diagnosed with pancreatic cancer?

Yes

Unsure

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17. Have you had genetic testing?

Yes

Unsure

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18. Would you be willing to share your story to help raise awareness?

Yes

Maybe (contact me with more information)

Patient Care Fund Application

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* 1. Full Name (Required.)

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* 2. Date of Birth (MM/DD/YYYY) (Required.)

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* 3. Home Address

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* 4. Email Address

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* 5. Phone Number (Required.)

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* 6. Gender

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* 7. Marital Status (Required.)

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* 8. Are you currently working? (Required.)

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* 9. Is your partner currently working? (if applicable).

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* 10. Hospital/Cancer Centre you receive care from (Required.)

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* 11. Referrals Received (check all that apply) (Required.)

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* 12. Age at Diagnosis

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* 13. Race/Population Group

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* 14. Do you currently smoke?

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* 15. Do you engage in regular physical activity/exercise (150 minutes of moderate-intensity or 75 minutes of vigorous-intensity aerobic exercise per week)?

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* 16. Has a first-degree relative (parent, sibling, child) been diagnosed with pancreatic cancer?

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* 17. Have you had genetic testing?

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* 18. Would you be willing to share your story to help raise awareness?

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* 19. Please briefly describe how this grant would help you.

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* 20. Please type your full name below. Your typed name will serve as your electronic signature. (Required.)

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* 21. Please upload your CRA Notice of Assessment from the year prior.

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* 22. Please upload a letter of diagnosis from your care team.

1. Full Name (Required.)

2. Date of Birth (MM/DD/YYYY) (Required.)

3. Home Address

4. Email Address

5. Phone Number (Required.)

6. Gender

7. Marital Status (Required.)

8. Are you currently working? (Required.)

9. Is your partner currently working? (if applicable).

10. Hospital/Cancer Centre you receive care from (Required.)

11. Referrals Received (check all that apply) (Required.)

12. Age at Diagnosis

13. Race/Population Group

14. Do you currently smoke?

15. Do you engage in regular physical activity/exercise (150 minutes of moderate-intensity or 75 minutes of vigorous-intensity aerobic exercise per week)?

16. Has a first-degree relative (parent, sibling, child) been diagnosed with pancreatic cancer?

17. Have you had genetic testing?

18. Would you be willing to share your story to help raise awareness?

19. Please briefly describe how this grant would help you.

20. Please type your full name below. Your typed name will serve as your electronic signature. (Required.)

21. Please upload your CRA Notice of Assessment from the year prior.

22. Please upload a letter of diagnosis from your care team.