Family Support Application

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

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

Parent / Guardian Information

We provide email updates and reminders regarding financial aid and applications, email addresses are a necessity for better serving families.
Does your family use social media such as Facebook, Instagram, or other formats to track treatment and spread awareness? *
Please Submit a Photo of Your Child *
Maximum upload size: 516MB

Parent / Guardian Demographics

Mailing Address *
Mailing Address
Does Parent / Guardian 2 Reside at the Same Address as Above *
Parent / Guardian 2 Address
Parent / Guardian 2 Address
Please be as accurate as possible. We may require proof of income.
Has Income Decreased as a Result of Diagnosis? *
Does the Family Receive Charitable Assistance from Other Non-Profits? *

Verification Information

Is there a 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? *

Medical Information

Has the Patient Experienced a Relapse? *
Is the Patient Undergoing any Clinical Trials as Part of Treatment? *
Has the Family Used, or Considered Using Compassionate Use/Expanded Access to Receive Treatments? *

Qualitative Information

Please provide a copy of the bills requesting to be paid.
Maximum upload size: 516MB

Signature Block

Who is Filling Out the Application? *