Family Assistance Request

Please fill out this request form if you need financial assistance due to your child’s cancer diagnosis. If your child is deceased and you need funeral assistance, please type “Funeral” in the fields that ask about treatment.

Patient's Name *

First

Last

Select One *

Patient's Date Of Birth (MM/DD/YYYY) *

Child's Diagnosis *

Date of Diagnosis *

Name and Contact Information for Child's Oncology Social Worker *

By entering this information the parent acknowledges and gives permission for the social worker to confirm information and communicate with Henry’s Loving Team about their child.

Treating Hospital and/or Medical Facilities *

Parent/Guardian Name *

First

Last

Parent/Guardian Contact Information – Include Mailing Address and phone number *

Email *

Henry's Loving Team strives to bring awareness to Pediatric Cancer and would like to use photos and/or digital images of the children they help for news releases, education, and/or promotional materials. Please indicate your permission choice below and send all jpeg's to Chrissie@henryslovingteam.org. *

I give permission to HLT to use photos of my child.
I do not give permission to HLT to use photos of my child.