Circle of Light Assistance Application
Circle of Light is a non-profit organization, associated with Chadron Community Hospital and Health Services whose mission is to help breast cancer patients and their families in Box Butte, Dawes, Sheridan and Sioux Counties in Western Nebraska. Assistance can help with non-medical expenses as related to cancer care and treatment. There is a sincere interest by the Circle of Light program organizers and our regional communities to lend a hand to as many persons as possible who qualify for assistance.
Examples of needs that can be funded include (but are not limited to) travel, rent, utilities, food and medication. If you or someone you know find(s) yourself/themselves with a diagnosis of cancer and are in financial need, Circle of Light may be able to help.Please fill out the pre-application and either return it or mail it to: Circle of Light, c/o Chadron Community Hospital and Health Services 821 Morehead Street Chadron, NE 69337, or call the Hospital at 308-432-5586. Further information will be requested to complete a formal application to ensure that the applicant has access to the maximum funding available.
Name of cancer survivor:
If a child name of parents: ____________________________________________________
City: _________________________________ State: __________ Zip Code: ___________
Phone: Day ___________ Evening _________ Cell _________ E-mail ________________
Cancer Type: _______________________________________________________________
Date of cancer diagnosis: _____________________________________________________
Name of facility where diagnosis was made: ______________________________________
Physician(s) providing care for you: _____________________________________________
Physician(s) phone numbers if not local: _________________________________________
Please know every effort will be taken to maintain strictest confidentiality!
I authorize the Circle of Light and its designee, to secure information regarding my diagnosis and treatment of cancer.
Signature of Applicant or Guardian: ___________________________________________________
Relationship to Cancer Survivor ________________________________ Date: ________________
Form # 1