Family Support Application | Max Cure Foundation

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Thank you for your interest in the Roar Beyond Barriers Program at the Max Cure Foundation. This program provides systemic financial assistance for families whose children are in active treatment for pediatric cancer diagnoses. The Roar Beyond Barriers program works by providing financial assistance in the form of check, and these are disbursed quarterly. When inducted into the program, your family will be eligible for the first quarter the family is inducted into.

Decisions based on the support your family receives is based on a ratio of your yearly family income as compared to the Federal Poverty Level; it is important that you honestly and accurately report your income and the number of persons in your household – if you need to make revisions please contact us.

Roar Beyond Barriers Application

Demographic Information

Date of Application

First Name of Patient *

Last Name of Patient *

Patient Date of Birth *

Patient Gender *

Ethnicity of Patient *

Patient Education Level *

Patient Interests / Hobbies *

Please tell us about the patient's interests and hobbies.

Parent / Guardian Information

Name of Parent / Guardian #1 *

Parent / Guardian Email *

We provide email updates and reminders regarding financial aid and applications, email addresses are a necessity for better serving families.

Secondary Contact Email

Daytime phone of Parent / Guardian 1 *

Preferred Language of Contact *

Does your family use social media such as Facebook, Instagram, or other formats to track treatment and spread awareness? *

Yes

No

If yes, please provide a link here:

Please Submit a Photo of Your Child *

Maximum upload size: 516MB

Parent / Guardian Demographics

Mailing Address *

Mailing Address

Mailing Address

Mailing Address

City

City

State/Province

State/Province

Zip/Postal

Zip/Postal

Education Level Parent / Guardian 1 *

Race of Parent / Guardian 1 *

Marital Status *

Name of Parent / Guardian 2

Does Parent / Guardian 2 Reside at the Same Address as Above *

Yes

No

Custody Arrangements

Parent / Guardian 2 Address

Parent / Guardian 2 Address

Parent / Guardian 2 Address

Parent / Guardian 2 Address

City

City

State/Province

State/Province

Zip/Postal

Zip/Postal

Country

Country

Education Level of Parent / Guardian 2

Race of Parent / Guardian 2

Employment Status of Parents *

Describe the Type of Employment for Parent / Guardian 1

If Other - Please Describe

Describe the Type of Employment for Parent / Guardian 2

If Other - Please Describe

Living Situation *

Yearly Income of all Working Members of Household *

Please be as accurate as possible. We may require proof of income.

Has Income Decreased as a Result of Diagnosis? *

Yes

No

Please Describe Income Change

Does the Family Receive Charitable Assistance from Other Non-Profits? *

Yes

No

If Yes, Please Describe the Assistance and Name the Organizations

Number of Family Members Residing in the Home *

Please List the Name and Ages of all Siblings in or out of the Home *

Verification Information

Name of Hospital Submitting/Providing Primary Care *

Name of Social Worker *

Social Worker Direct Phone *

Email of Social Worker *

Is there a Child Life Specialist *

Yes

No

Name of Child Life Specialist

Email of Child Life Specialist

Do you authorize Max Cure Foundation to reach out and discuss this application and your family’s circumstance with the provided contacts above? *

Yes

No

I am the social worker submitting this form

Medical Information

Diagnosis of Patient *

Date of Diagnosis *

Date of Diagnosis *

Expected Length of Treatment *

Has the Patient Experienced a Relapse? *

Yes

No

If Yes, Please Describe

Briefly Summarize the Circumstance that Lead to Diagnosis of Patient *

Briefly Summarize the Expected Course of Treatment *

Other Relevant Medical Information

Is the Patient Undergoing any Clinical Trials as Part of Treatment? *

Yes

No

If Yes, Please Describe.

Has the Family Used, or Considered Using Compassionate Use/Expanded Access to Receive Treatments? *

Yes

No

If Yes, Please Describe. *

Qualitative Information

How is your family coping with your child’s diagnosis? Is the family receiving emotional counseling or other psychosocial support? *

How has the impact of diagnosis affected the emotional well-being of the patient? *

Describe the economic situation of the family. Has the family experienced difficulty paying bills, buying foodstuffs, or needs help navigating other financial aid? *

Please provide a short family bio that describes the entire household’s situation. *

Does your family have access to banking services, or can your family cash a check? Max Cure provides quarterly financial assistance by check, but in special circumstance can provide other forms of aid. *

Has your family ever considered becoming involved in advocacy efforts to bring awareness to pediatric cancer causes? *

Type of Support Requesting *

Please describe your emergency needs

Please provide a copy of the bills requesting to be paid.

Maximum upload size: 516MB

Signature Block

Who is Filling Out the Application? *

Parent / Guardian 1

Parent / Guardian 2

Patient Social Worker

By entering my initials below I certify that the information submitted in this form is true and correct to the best of my knowledge, and that I am seeking assistance for my child in active pediatric cancer treatment on this date. *

By entering my initials below I certify that the information submitted in this form is true and correct to the best of my knowledge, and that I am seeking assistance on behalf of the child and family in question who are battling a pediatric cancer diagnosis. *

If you are human, leave this field blank.

Main office

To learn more about the Max Cure Foundation please contact us at

100 Wall Street, Suite 900, New York, NY 10005
201-569-5595
info@maxcure.org
@MaxCureFoundation

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