Financial Support Application | JoJo Siwa Childhood Cancer Foundation

Please complete the application and submit the form. If your application is approved we will contact you.

Childs Name(Required)

First Last

Child's Date of Birth(Required)

Parent/Legal Guardian Name(Required)

First Last

Referral/Nominator Name

First Last

If referring someone to be considered, please include your name, email, and phone number.

Referral's Phone Number

Referral's Email

Does the family you are referring, know that you are submitting an application?

yes

Parent's Phone Number(Required)

Paren'ts Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Parent's Email(Required)

Link to Caring Bridge, Facebook page, etc. (if available)

What is your story?(Required)

Has the potential recipient received funding from other organizations/charities?(Required)

yes

If yes, disclose the name of the organization.

Provide a photo of applicant(Required)

Accepted file types: jpg, jpeg, png, gif.

Please submit medical documentation to verify the diagnosis of patient seeking financial assistance.

Max. file size: 100 MB.

Parents please provide this documentation at time of application. If referring someone, we will contact the potential recipient for more information.

This field is for validation purposes and should be left unchanged.