Request for Financial Assistance

Requirements for Financial Aid:

The family applying for assistance must have a child 18 years of age or younger who is currently receiving treatment for pediatric cancer or was hospitalized due to complications from cancer treatment within the last 30 days.
The family must reside in Rock County.

If the family meets the requirements above, please complete the form on this page and click “Submit Application”.

As an alternative, you can download a hard copy of the form here, and email the completed form to isaacstrongfoundation@gmail.com or mail a hardcopy to:

The Isaac Strong Foundation

PO Box 943

Janesville, Wisconsin 53547

Child's Name

The name of the child in need of financial assistance.

First Name

Last Name

Child's Date of Birth

The date of birth of the child in need of financial assistance.

YYYY

Parent/Legal Guardian Name:

The name of the child's parent or legal guardian.

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Email address of the parent/guardian.

Phone Number

Phone number of the parent/guardian.

(###)

###

####

Child's Diagnosis

Please describe the child's medical diagnosis

Date of Diagnosis

The date of the child's diagnosis.

YYYY

Date of Last Treatment or Hospital Stay

The date of the most recent treatment or hospital stay.

YYYY

Child's Physician's Name

The name of the child's physician.

First Name

Last Name

Hospital Name:

The name of the child's hospital

Hospital Address

The address of the child's hospital.

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Social Worker's Name and Title

The name of the child's social worker and title.

Social Worker's Phone Number

The social worker's phone number and extension if applicable.

Social Worker's Email

The email of the social worker.

Criteria for Funding

Please describe the current treatment or hospital stay that makes the child eligible for funding. For assistance, see the requirements at the top of this page.

Child's Facebook Page if Applicable.

Please provide a link to the Child's Facebook page if they have one.

The Isaac Strong Foundation has a website and social media accounts to help the community understand our mission and support our heroes.

Do we have permission to use this child's story on the Isaac Strong Foundation website? Please indicate yes or no.

Social Worker Signature

This checkbox will serve as an electronic signature. By clicking "I agree", you attest that the information provided in this form is completed to the best of your ability.

I agree

Request for Financial Assistance

Isaac Strong Foundation

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