Apply for Assistance

Does your child have cancer? It is OK to ask for help. It is OK to lean on others to provide hope. We believe in making a difference, one child at a time

Carol’s Hope for Childhood Cancer is here for you. Please fill out the form below or call (864) 978-1821.

Date(Required)

Date format: mm/dd/yyyy

Hospital(Required)

Personal Information

Patient Name(Required)

First Last

Patient Diagnosis(Required)

Is patient in treatment?(Required)

Yes

How long?

Parent(s) Name(Required)

Sibilng 1

Date of Birth

Date format: mm/dd/yyyy

Sibling 2

Date of Birth

Date format: mm/dd/yyyy

Sibling 3

Date of Birth

Date format: mm/dd/yyyy

School District

The school district must be in the South Carolina Upstate.

Address where child lives(Required)

Street Address Address Line 2 City State ZIP Code

Phone

Cell Phone

Email(Required)

Brief explanation of need/request for assistance

Date funds or assistance is needed

Date format: mm/dd/yyyy

How did you hear about us?

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