JustInTime Grant

Application

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Must be 18 years of age or older
Must have at least one dependent
Applicant or a dependent have a cancer diagnosis and are receiving active treatment
Must be experiencing financial hardship
Must be living in or treated in Minnesota

Eligibility:

JustInTime Grant Application

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

pATIENT information

If different from applicant (otherwise leave blank)

May we leave a message on your phone?

Yes

Inform me regarding my application via:

By Phone

By Email

Other

MEDICAL information

Type of Cancer diagnois

Stage

Patient's current treatment

Clinic/Hospital Name

Ongologist Name

City

Ongologist Phone Number

HOUSEHOLD information

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

Financials information

Total Monthly Household Income (after taxes):

Requested Amount (up to $1,000)

Why are you requesting financial assistance?

What is your current housing situation?

Stable

Unstable

Homeless

Perfer 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 JustInTme Grant

Social Worker

Patient Navigator or Counselor

Nurse

Doctor

Friend or Relative

Internet

Other

Thanks for submitting! Someone from the Justin Kukowski Foundationwill be in contact with you shortly.

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