Apply for Financial Assistance

**Please note that we are only accepting applications from the Miami, Florida area.

Please fill out the web form below, OR click here to download and print this form in Adobe pdf format (Adobe Reader Required) and submit via postal mail to:

The American Foundation for Children with Cancer
847 West 18th St, Hialeah, Fl 33010

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1. New Field

Apply Online

1. Patient Name(required)
2. Birth Date(required)
3. Parent/s or Guardian Name(required)
4. Telephone Number(required)
5. Parent or Guardian Address(required)
6. City
7. Florida, Zip
8. Are you currently employed?
9. Yes No
10. If so, where?
11. What type of Cancer does the Child have and what treatment are they undergoing?(required)
12. What bills are you seeking assistance for and how much? Please be Specific.(required)
13. *AFCC may require a copy of the bills which financial assistance is being requested for.
14. Are you currently receiving aid or assistance from any other charity?
15. Yes No
16. If so, how much and from whom?
17. As part of our ongoing efforts The American Foundation for Children with Cancer requires a photo of the child.
18. Do you agree to have you and your child’s picture taken?
19. Yes No
20. Also, we may use your child’s story on our website and or press release. AFCC does this to elicit further funds and to show our efforts and charity in the community.
21. Do you agree to AFCC using your child’s story?
22. Yes No
23. In order to receive assistance you must agree to the aforementioned, if not we may not be able to provide all the support requested. I understand The American Foundation for Children with Cancer (AFCC) may verify the financial information contained in this Financial Assistance Application (“Application”). I certify that the statements made in this Application are true and correct, to the best of my knowledge and belief, and are made in good faith. I am aware that falsification or misrepresentation of information on this Application may result in denial of financial assistance.
24. Signature of Parent(required)
25. AFCC Employee Signature if any part of Application Completed by an AFCC Employee
26. Human Verification- In the field below, type what you see in the image

 

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