Light of Hope Foundation logo_gradient_2 color.png

Light of Hope Application

Light of Hope Statement:

To provide practical and immediate financial support to local cancer patients and their families so they can focus on healing.

Please read the following paragraph before completing the application:

To be eligible, you must reside in Rice County (be a permanent resident of MN) or receive treatment in Rice County; and in active treatment for cancer, including chemotherapy/immunotherapy, radiation, and/or surgery with a recovery time of more than four weeks.
Financial Program Grants are available to oncology patients to provide additional financial assistance due to extreme hardship.
Financial Program applications are considered and processed pursuant to Light of Hope guidelines, which are available online or a hard copy can be provided upon request for details.
Please have the first and last name and contact information of your Social Worker, Nurse Navigator, or Medical Provider.
Financial Program Grants are generally paid directly to the company owed. Please have the name, your account number and the address of the company owed ready. LOH is not able to reimburse for expenses/bills already paid
Have not received Light of Hope Cancer Foundation Funding in the prior 12 months of application date.
Maximum funding for 2025 is $1,500 per individual per calendar year.

Patient Information

First name

Last name

Primary Address

Phone

Birthday

Month

Day

Year

Have you received assistance from Light of Hope in the past 12 months? Please check your answer.

Yes

If yes, approximately what date did you apply?

Gender (please check one)

Male

Female

Prefer Not To Disclose

Other

Family Information

What is your annual household income?

How many family members reside in your household?

Please indicate any/all treatment-related hardships (check all that apply): (At least one box required)

One or more inpatient hospitalizations in the past 90 days

Current treatment for cancer

Immediate family member(s), who are uninsured and unemployed, have (or had) a serious chronic illness in the past 12 months

None of the above apply

Employment and Life (check all that apply): (At least one box required to be checked)

Patient earns primary income

Patient is on unpaid leave or unemployed

Patient is currently receiving short-term disability

Other adults in home are on unpaid leave or unemployed

Patient does not have reliable transportation

Patient does not have stable housing

Patient does not have health insurance

Retired

None of the above apply

In order to help us understand your needs, please provide additional detail related to any boxes you checked in the Employment and Life section.

Please provide any additional information such as date of onset, treatment status, family dynamics, and economic situation (family or personal) that would be helpful to evaluate the application:

Hospital/Clinic Information

Name of Primary Cancer Center Care Facility

Address

Name of Social Worker/Healthcare Provider (First & Last):

Phone Number and/or email of Social Worker/Healthcare Provider:

Grant and Payment Information:

Check Payable To (Name of Creditor):

Account Number with Creditor:

Creditor Address

Creditor Phone

Requested Amount:

Due Date:

Additional comments on the amount/type of request:

Authorization (paragraphs 1 and 3 are required)

I authorize the verifier (healthcare provider, social worker, etc.) provided on this form to release information (including diagnosis, treatment status and other pertinent information related to grant request) to Light of Hope Foundation as necessary to determine eligibility and processing of this grant request.

I would like to share my story; my cancer journey and how Light of Hope Foundation has helped me. Please contact me.

I understand that my personal information will not be published or shared with the public or a third party, except as provided herein, without my consent. Personal information is defined as home address, phone number, email address, medical information, and creditor information.

I would like to keep up to date on Light of Hope Foundation’s work in the community. Please include me on your newsletter and mailing distribution.

I have not received assistance from the Light go Hope Cancer Foundation in the prior 12 months of the date of my application.

Applicant Signature

Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.

Person Completing the Form:

Relationship to Person Completing the Form:

Today's Date

Month

Day

Year

*A COPY OF BILL MUST BE INCLUDED WITH APPLICATION (on

conditions boxes checked are not transportation or grocery.

File upload

Light of Hope Cancer Foundation Website: www.lightofhopemn.org

Email Address: info@lightofhopemn.org

Mailing Address: PO Box 934 - Faribault, MN 55021