New Patient Application
Instructions:
Who can submit an application? The patient's social worker or medical staff ONLY.
Parent/guardian: contact your social worker.
Social worker / medical staff: contact info@bumblebeefoundation.org. Once we add you to our site, enter your email address in the box above to login and access the form.
Who is eligible for assistance? Children 18 & under, residing in California or Idaho, with a cancer diagnosis, currently in treatment or within a year of finishing treatment.
What information is required for the form? IMPORTANT: collect all information first. There is no option to save and revisit the form.
You'll need:
- Patient name, address, DOB, diagnosis and date (relapse dates if applicable)
- Parent/guardian address, phone, email
- Social worker contact info, hospital, hospital contact info
- Patient family gross income, fundraising efforts, sources of assistance.
- Assistance request & explanation of request