Creating Brighter Days for Kids with Cancer

Patient Families

*Parents, please fill out our Patient Family form so that we may be able to better serve you.

Name of Child on Treatment:
Birthdate: ex: mm/dd/yyyy
Date of Diagnosis: ex: mm/dd/yyyy
Date of Relapse: ex: mm/dd/yyyy
Treatment Facility:
Name of Social Worker:
Parents/Grandparents/Guardians name(s):
Phone Number: ex (618) 222-2222
Email Address:
Sibling 1:
Sibling 1 Gender:
Sibling 1 Birthdate: ex: mm/dd/yyyy
Sibling 2:
Sibling 2 Gender:
Sibling 2 Birthdate: ex: mm/dd/yyyy
Sibling 3:
Sibling 3 Gender:
Sibling 3 Birthdate: ex: mm/dd/yyyy
Sibling 4:
Sibling 4 Gender:
Sibling 4 Birthdate: ex: mm/dd/yyyy
Child on treatment lives with:
Additional Information:
(i.e., special birthday wish, gas stations/grocery stores near you)
I give permission to use photograph
I DO NOT give permission to use photograph
Key Phrase:
Enter Key Phrase:
financial assistance application form
The average length of treatment for children with cancer is 3 months to 3.5 years. Non-medical expenses, on average, assume approximately 38% of a family's gross annual income. These expenses include, but are not limited to travel to and from the treatment center, accommodations and meals away from home, and daycare expenses for other young children in the home. In addition, approximately 43% of families have a parent either give up or reduce employment to care for the child. These lost wages, along with out-of-pocket medical expenses account for nearly HALF of a two parent income. The financial strain is considerably greater in single parent families. It is not uncommon for childhood cancer families to lose all assets and emotional stability in the process of providing the best possible care for their child.
To see if you qualify for financial assistance, please contact your child's Hematology/Oncology social worker at your child's place of treatment in the Greater St. Louis area.

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