Application for Financial Assistance

*Please note: As much as we would love to be able to help all families fighting cancer, that is not possible for us at this time. We have chosen to focus on families located in the Intermountain West. Any easy way to determine if you are in our area is that we focus on families that live in the areas serviced by Primary Children’s Hospital. You do not have to be receiving treatment at Primary Children’s Hospital, just live in that geographic area.

After submitting this application you will receive an email with an attached form requesting a statement from your child’s physician confirming your child’s diagnosis. ¬†Income and debt statement verification may also be requested (most recent pay stubs, etc.).