Financial Assistance Application

Financial Assistance Application

Program Qualifiers
Financial Assistance is available for patients currently undergoing active colorectal cancer treatment. Applicants previously awarded funding through this program are not eligible.

Treatment Information
Please provide information about the patient's cancer diagnosis and the current treatment plan.

Patient Information

This is the address where the funding will be sent

Email address required. MUST be a valid email address as this will inform applicant of approval or denial.

enter as MM/DD/YYYY

Other information

I, the named Applicant, attest and certify, under penalty of law to the Colorectal Cancer Alliance and the agents lawfully acting on its behalf, that the information provided in my application is complete and accurate. I understand that reported financial information may be verified by an audit, as deemed necessary by the Colorectal Cancer Alliance. I further understand that any false or incomplete information provided by me in this application could unduly harm the Colorectal Cancer Alliance, its reputation and its tax exemption status and, therefore, may also constitute fraud for which I may be legally liable. I also understand that, if I am approved for assistance by the Colorectal Cancer Alliance, assistance will terminate and the Colorectal Cancer Alliance may recoup the amount of any financial assistance provided to me if the Colorectal Cancer Alliance becomes aware of any inaccurate information or fraudulent activity relating to my application or the assistance provided to me by the Colorectal Cancer Alliance. Finally, I understand that I am not guaranteed or promised assistance, and that any assistance the Colorectal Cancer Alliance may provide is limited to the terms and conditions established by the Colorectal Cancer Alliance and that the Colorectal Cancer Alliance reserves the right at any time and for any reason, without notice, to: (i) modify this application form, (ii) modify or discontinue any assistance provided by the Colorectal Cancer Alliance or the Colorectal Cancer Alliance’s eligibility criteria or (iii) terminate assistance. By submitting this application, you grant the Alliance and its successors and licensees and assign unlimited rights to share your story. If awarded, the Alliance may contact you to conduct an interview.

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