Family Grant Application – Lilly Lights the Way

Please review our guidelines for eligibility before completing this form.

The Lilly Lights the Way Childhood Cancer Foundation provides family grants of up to $750 to help patients, who are battling cancer, with expenses. This grant will allow families to focus on spending precious, quality time together rather than paying expenses.

In order to receive such grant a patient must live in the Northeastern part of the United States and be in active cancer treatment.

We are happy to assist with the following expenses:

housing (mortgage/rent)
utilities (electric, oil, gas)
medical expenses (transportation, hospital parking, medication, medical equipment).

Patients should work directly with their social worker to apply for financial assistance through LLTW foundation. If applicable, financial grants will be mailed directly to the provider/vendor.

If you meet the eligibility criteria, please apply by completing the form below.

Please enter your personal and medical information.

You can fill this form out online and submit it. Or download the PDF - Please complete it, sign it, and send via email to apply.lillylightstheway@gmail.com PDF Form Here.

If you choose to use the PDF Form, please mail it to: Lilly Lights the Way, P.O. Box 374, Attleboro, MA 02703

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Child's Legal Name:

First

Last

Date of Birth

(mm/dd/yyyy)

Gender

Male
Female
Nonbinary

Parent/Guardian Name:

First

Last

Address:

City:

State:

Zip Code:

Home Phone:

( Area Code ) -

Cell Phone:

( Area Code ) -

Email Address:

Confirm Email

Annual Household Income:

Please include ALL sources of income

Requested Grant Amount

Please provide a dollar amount

Intended Use of Grant:

If applicable, please provide bills paid directly to the vendor with the vendor name, account number, mailing address, familt's last name, and the dollar amount owed.

Parent/Legal Guardian's Signature*:

Application Date:

Please Note: Need to upgrade to PRO Form to hide the box

*By signing this application, you are agreeing to allow publication of your child’s name, medical condition and/or likeness by The Lilly Lights the Way Childhood Cancer Foundation. Additionally, by signing this, you are giving your medical professionals and LLTW permission to share medical information about your child’s case. Finally, by signing this, you are consenting to allow LLTW to share your application with other organizations in an effort to potentially gain additional funds for you.

Child's Diagnosis:

Date of Diagnosis:

(mm/dd/yyyy)

Child's Physician:

Hospital

Hospital Address:

City

State

Zip Code:

Social Worker's Name and Title:

Social Worker's Direct Phone and Extension:

Social Worker's Email Address:

Confirm Email

Please decribe the child's medical condition, anticipated hospital stay, and any other notable facts.

Please attach a separate document if you need more room to write).

Social Worker's Signature:

Date Signed:

By signing this application, you are attesting to the accuracy of the information on both pages, to the best of your knowledge. Please be sure that the entire application is complete before submitting it. Incomplete applications will be returned to you.

Lilly Lights The Way