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Just-In Time Grants
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Just-In Time Grant Application

Eligibility

Grants available to all ages
Applicant or a dependent has a cancer diagnosis and is receiving active treatment
Must be experiencing financial hardship
Must be living in or treated in Minnesota

Please select one of the following options: *

I am the patient, applying for myself

I am an oncology health care professional assisting the patient

I am assisting the patient, and my relationship to the patient is:

Applicant Information

Applicant First Name

Applicant Last Name

Applicant Address

Applicant Phone Number

Applicant Email Address

Patient Information

If different from applicant (otherwise leave blank)

Patient First Name

Patient Last Name

Patient Address

Patient Phone Number

Patient Email Address

May we leave a message on your phone? *

Yes

Inform me regarding my application via: *

Phone

Other:

Medical Information

Type of Cancer Diagnosis

Stage

Patient's Current Treatment

Clinic/Hospital Name

Oncologist Name

City

Oncologist Phone Number

Household Information

Please list the members in your immediate household, including names, relationship, and ages of dependents:

Financial Information

Total Monthly Household Income (after taxes)

Requested Amount (up to $3,500)

Why are you requesting financial assistance?

What is your current housing situation?

Stable

Unstable

Homeless

Prefer not to answer

Additional Information

Provide additional comments regarding your situation that might be helpful when reviewing your application:

I declare that the information on this application is true and correct to the best of my knowledge. I understand that all applications will be reviewed on a case-by-case basis and final determination will be made by Justin Kukowoski Foundation. I hereby give my permission that this application and all information provided can be sent to Justin Kukowski Foundation and discussed with my health care professional. All information reviewed is confidential.

I accept terms & conditions

I understand that this serves as my digital signature

Select a date

How did you hear about the Just-In Time Grant?

Social Worker

Patient Navigator or Counselor

Nurse

Doctor

Friend or Relative

Internet

Other

Thank you for your application! We will be in contact with you soon.

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