Name (First Name, Last Name) (required)

Address: (required)

City (required)

State (required)

Zip Code (required)

Phone (required)

Email (required)

Contact Person (required)

Amount Requested (required)

Type of Request (Cash, Gas Card, Assistance with an Event, Meal Train, Etc.)

Are you, a family member or friend currently battling cancer? yesno

If yes, relationship?

What type of cancer:

Diagnosis Date:

Is this person a current/past resident of Humboldt County? yesno

If yes, when?

Have you previously received assistance from the California Cancer Crushers? yesno

If yes, when/what?

Would you like a list of resources? yesno

Would you like to share other agencies who have assisted you?

How did you hear about the California Cancer Crushers?

Please describe your need for assistance and how you plan to utilize any assistance provided.

I certify that my answers are true and complete to the best of my knowledge.

If this application leads to assistance being provided, I understand that false or misleading information in my application may require funding be withheld or paid back.