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: ____________________________________________________

            Address: __________________________________________________________________

            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