Apply for Assistance

PLEASE RED BEFORE APPLYING:

Applicants must live in the Hampton Roads area in order to be considered for assistance. This includes the cities of Chesapeake, Hampton, Newport News, Norfolk, Poquoson, Portsmouth, Suffolk, Virginia Beach and Williamsburg, and the counties of Gloucester, Isle of Wight, James City, Mathews, Surry and York.

Applications must be completed by the cancer patient seeking assistance, or by an agent under a Durable General Power of Attorney. We will not consider applications placed by friends or family members.

All applicants will be required to participate in an in person interview with two of our board members. The application will then be considered by and voted on by the Board of Directors at the next meeting following the interview, and applicants will then be notified of the board’s decision. In certain cases, a video interview will be considered if the applicant’s circumstances prevent an in person interview.

Application

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Full Name

First

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone

Briefly tell us your story.

Stage & type of cancer.

Who is your doctor?

How has cancer changed your finances?

Wills and Powers of Attorney Clinic

Please contact me about your free Wills and Powers of Attorney clinic.

What are your needs? (Check all that apply)

Professional assistance
Help with domestic animal(s)
Household chores (cleaning, meal prep, yard work, etc)
Other

If other, please explain your needs.