Financial Assistance Grant Application

Date of Hospital/Facility

ELGIBILITY: All applicants must be U.S. residents. Candidates must be the brain tumor patient; parent/guardian of; or a financially bound relative of a person diagnosed with a brain tumor. Relationships are limited to spouse, children, parents, and siblings. All applications require the signature of the patient/next of kin; parent/guardian and must be accompanied by proof of a brain tumor diagnosis such as hospital statement showing services related to diagnosis. Supporting documentation regarding financial hardships during and/or following the diagnosis should also accompany the application (ex. past due hospital bills).

Note: Funds will be distributed on a first come first serve basis (check website for availability Funds are made payable to the patient or next of kin if patient has transitioned; parent/guardian. Maximum amount awarded is $2500.00.

A HUSBANDS HOPE: Must be the HUSBAND of the brain tumor patient. Must demonstrate financial hardship during and/or after the diagnosis.

A WIFE’S WISH: Must be the WIFE of the brain tumor patient. Must demonstrate financial hardship during and/or after the diagnosis.

A CHILD CARES: Must be age 18 or older. Must be the CHILD of the brain tumor patient. Must be a caretaker of the brain tumor patient. Must demonstrate financial hardship during and/or after the diagnosis.

MY BROTHER'S/SISTER'S KEEPER: Must be age 18 or older. Must be the SIBLING of the brain tumor patient. Must be a caretaker of the brain tumor patient. Must demonstrate financial hardship during and/or after the diagnosis.

A PERSISTENT PATIENT/PARENT: Must be a brain tumor SURVIVOR or parent/guardian of a minor previously or currently diagnosed with a brain tumor. Must demonstrate financial hardship during and/or after the diagnosis.

Name

First

Last

Relationship to Patient

Applicant Email

Phone

PATIENT INFORMATION

Patient's Name

First

Last

Home/Mobile Phone

Home Address

Address Line 1

Address Line 2

City

State

Zip Code

DIAGNOSIS INFORMATION

Date of Diagnosis

Type of Tumor

Hospital/Facility Name

Hospital/Facility Phone

Hospital/Facility Address

Address Line 1

Address Line 2

City

State

Zip Code

GRANT INFORMATION

Grant Amount Requested

Funds Utilization

APPLICANT ATTESTATION

I have read and understand the terms of this financial award and will comply with all the requirements. If selected as a grant recipient, it may be necessary to provide additional information and/or verification to Mary E. Smith (M.O.M) Foundation, Inc./Memories of Mary. I further agree to grant permission to my healthcare provider/facility to disclose mine or my loved one's diagnosis. If I am the patient, I certify that I willingly provided my medical information solely for the purpose of gaining financial support. I agree to the use of my initials or last/family name & abbreviated situation to be shared in MESF materials/website regarding award distributions by MESF to the charities donors/support base. I/We certify that the information provided is accurate to the best of my/our knowledge.

By signing (typing your legal name) in the space below, you are certifying that all information is correct and that you are the person completing this application. When you press the submit button, you will receive an email confirmation that your application was received. Please retain for your records as verification of your application.

Checkboxes

I agree
I do not agree

I agree with the above statement and will provide the date & my signature below...

Date / Time