Grant Application To be considered as a grant recipient, please fill out the application below. Please enable JavaScript in your browser to complete this form. - Step 1 of 3First Name *Last Name *Age *Preferred PronounsEmail *Phone *Note *Please add “[email protected]” to your email contacts so you can be sure that you will receive our emails. If you haven’t received an email that you are expecting to, please check your spam and junk folders. (Please check the checkbox to acknowledge before continuing.)NextWhere are you from? *Why are you applying for this membership grant? *Type of cancer *Stage of cancer *In Post-TreatmentAre you in Post-Treatment?What are you looking for in a support team/community? *Are you active-duty military or a veteran of the armed forces?Active-DutyVeteranNextApproximate Annual Income (in $USD) *Less than $20,000$20,000 to $34,999$35,000 to $49,999$50,000 to $74,999$75,000 to $99,999Over $100,000Medical Provider Name *Were you referred to Cancer Champions by your oncologist and/or physician? *YesNoWhat is the name of the person who referred you? *How did you hear about Cancer Champions? *Do you have insurance? *Please note: insurance has NO impact on the application processDo you speak English? *YesNoSubmit We take your privacy seriously. The information you submit is sent directly to us, and is NEVER SHARED.