Patient Application

 
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Before completing the application, please note:

Pinky Swear processes applications monthly.

  • Applications are due the last day of the month, and reviewed and distributed the following month. For example, if you apply in November, your request will be reviewed in December.

  • Do not submit multiple applications within the month 

  • Meeting the criteria in this application does not guarantee approval.

  • Pinky Swear will notify by email the primary contact and social worker listed whether or not your request was approved.

  • Grants that are approved will be dispersed the last week of each month.

  • Please remind your social worker to sign a release of information so they may verify your request. 

To complete the application you will need:

  • Your clinical social worker's contact information. Please do not submit the application if you do not have your social worker's information. 

  • An electronic copy of the bill you are requesting assistance for.

  • Please submit your applicaiton through the online form only. We can not accept fax or printed applications.

Do you have or know a child diagnosed with cancer in the last 6 months? Pinky Swear Orange Envelope is also here with a virtual hug.

Patient Information