Patient Information

* Required

Who is filling out the application?

Oncology Professional's Name:

Oncology Professional's Title:

Oncology Professional's E-mail:

Your Name:

Please indicate your relationship to the patient you are applying for.

I am applying for:

Emergency Financial Assistance (EFA) Financial Cancer Care (FCC) Program Adult & Family Programs (AFP)

I am applying for:

General Assistance Grant Margie and Mark's Grant Angel in Action Grant

Please tell us why you are in need of Emergency Financial Assistance.

Please tell us why you are interested in learning how to build a financial plan?

Please tell us why you are interested in participating in our Adult & Family Programs?

First Name

Middle Initial

Last Name

Preferred Name

Birth Date

Street Address, Apt.#

City

State

Zip Code

County

Phone/Mobile

Please list others we can discuss your application with besides your oncology team.

Employer

Medical Insurance Provider

Would you like Angel Foundation to contact you regarding other community resources?
Yes No

May we leave a message on your phone?
Yes No

Do you need language translation?
Yes No

Demographic Information

Your responses to the following questions enable Angel Foundation to better serve communities equitably. All responses are kept private and secured and will NOT be used for discriminatory purposes.

What gender do you identify as?

Are you a United State Military Veteran:
Yes No

What category describes you?

Marital Status

After completing this online form, a more detailed Medical Information Form (PDF) will be emailed to you. This additional form is to be completed by a member of your oncology treatment team such as a social worker, nurse, patient navigator or doctor and returned to Angel Foundation by email at grants@mnangel.org or by fax to (612) 338-3018 . If you need assistance with the Medical Information Form or have questions, please contact Angel Foundation.

Type of Cancer Diagnosis

Cancer Stage

Treatment Type

Date of most recent or next treatment

Clinic/Hospital Name

City

Household Information

Please list the total number of people living in your household including yourself:

Do you have school-aged children in your household (5-18)?
Yes No

What is your housing situation?

Total Net Monthly Household Income (after taxes)

Additional Information

How did you hear about Angel Foundation?

May we add you to our mailing list?
Yes No

Will you be willing to share your story with our community?
Yes (This is not required to receive assistance. If you choose yes, someone from Angel Foundation may contact you.)
No

Please list anything else you would like us to know.

I declare the information on this application is true and correct to the best of my knowledge. I understand that each application is reviewed on a case-by-case basis, and the final decision will be made by Angel Foundation.
I hereby give my verbal permission that this application and all information offered can be provided to Angel Foundation and discussed with my healthcare professional. I understand that all information reviewed is confidential.

Signature

Date of Signature

Patient Information

Demographic Information

Medical Information

Household Information

Additional Information

Patient Release