Team Campbell Foundation Assistance Program Application

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Louise Hamilton
5 years ago
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Team Campbell Foundation Assistance Program Application Campbell s family knows firsthand how childhood cancer affects the entire family in every possible way.

such as a family outing to a sporting event or Broadway show, or to help relieve some of the financial burden associated with treatment including, but not limited to, specialized therapy, medical

1 Team Campbell Foundation Assistance Program Application Campbell s family knows firsthand how childhood cancer affects the entire family in every possible way. The Team Campbell Foundation ( TCF ) Assistance Program aims to provide a psycho social enrichment opportunity based on the interests of the child with cancer, the parents or the patient s siblings, such as a family outing to a sporting event or Broadway show, or to help relieve some of the financial burden associated with treatment including, but not limited to, specialized therapy, medical equipment, etc. If you would like to be considered for this program, please complete the attached application, and forward to your social worker or oncologist for his/her statement and signature. The completed form should be returned to familyassistance@teamcampbellfoundation.org. Applications will be considered as they are received. Families will be notified within 30 days of receipt of application regarding if/how TCF can help. The Team Campbell Foundation was formed in late 2014 in memory of Campbell Hoyt, who courageously battled Anaplastic Ependymoma, a rare cancer of the brain and spine, for 5 years before passing away in August of 2014 at the age of 8. The mission of the foundation is to improve the lives of families facing a childhood cancer diagnosis through raising awareness, funding research and providing psycho social enrichment opportunities. Sincerely, The Team Campbell Foundation PO Box 556 Bernardsville, NJ Team Campbell Foundation is a registered 501(c)(3) tax exempt organization. Federal Tax ID POBox 556 Bernardsville, NJ 07924

2 IMPORTANT! Please make sure you follow these instructions completely. Incomplete applications cannot be processed. Must include the address of the social worker or oncologist Must be typed or very clearly printed Mail or Completed Application To: Team Campbell Foundation PO Box 556 Bernardsville, NJ Questions? Patient s Name: Diagnosis: Age at Diagnosis: Grade/Stage: Current Age: Primary Treating Hospital: Street Address: City, State, Zip Country Treating Oncologist s Information: Name: Phone: Social Worker Information: Name: Phone: 1

3 Parent(s)/Guardian Name(s): Mailing Address City State Zip Address Phone Number Family Size: Names and Ages of Siblings: Patients Interests (such as Broadway shows, baseball, ballet, horses, American Girl Dolls, sports team, etc.) Approximate Annual Household Income (please check): Under $25,000 $25,000 $50,000 $50,000 $75,000 Over $75,000 2

4 Family Statement Please describe how your child s cancer diagnosis has adversely affected your family relationships and/or financial situation, as well as what your child(ren) is(are) most interested in. Attach separate page(s) if necessary. Parent Signature: Date: 3

5 Social Worker / Oncologist: Please complete this form for the family and mail/ to Team Campbell Foundation. Applications must be signed and submitted by the patient s social worker and/or oncologist to be considered. Social Worker/Oncologist Statement: Please provide any additional information that will assist us in the decision making process relative to the family situation, current financial status, prognosis, etc. Social Worker/Oncologist Signature: Date: 4

6 Media Release Form I hereby give my permission for the Team Campbell Foundation and/or its representatives to use photographs, audio or video recordings of my child(ren) or myself and to use our first names, these images or recordings in publications, slides, videotapes, motion pictures or on the internet. I understand that these visual images or voice recordings will be used to inform families, volunteers, the media and general public about Team Campbell Foundation s mission, programs, services and events. I gladly give this authorization to support the efforts of Team Campbell Foundation. I understand that this authorization shall continue until terminated in writing. Children s Name(s) (patient and siblings): Parent/Guardian Signature: Address: Date: 5

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