New Patient Application

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