Cancer Community Support Grocery/Gas Card Application

The Northern New England Clinical Oncology Society Cancer Community Support Grocery/Gas Card Program is designed to support the emergency needs of patients with cancer in Northern New England (Maine, New Hampshire, and Vermont) facing food insecurity and related financial toxicities. Practices/clinics are eligible to apply for gift cards to distribute to patients to provide direct, emergency assistance on behalf of NNECOS. Recipients of the cards must be hematology/oncology patients under active treatment or receiving palliative care services as they approach hospice. Each site must identify a champion to take responsibility for program implementation, accountability, and regular reporting. These cards ($25 each) are provided as a gift to patients from NNECOS.

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* 1. Applicant Contact Information:
Please list the site "champion" who will accept responsibility for this program.

Name *

Organization *

Address *

Address 2

City/Town *

State *

ZIP Code *

Email Address *

Phone Number *

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* 2. Approximately how many patients does your site/clinic serve each month?

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* 3. Describe the infrastructure your organization has in place to efficiently and accountably distribute cards to patients in need. Please include details about how you track card distribution.

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* 4. Please specify the number of cards requested in each category and the vendor from whom you'd like the gift cards purchased.
A maximum of 120 gift cards total will be awarded per eligible practice until funding is exhausted.

# of Grocery Gift Cards

Grocery Store Name:

# of Gas Cards

Gas Station/Vendor Name:

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* 5. Are you receiving funding from other charitable entities to support similar activities?

Yes

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* 6. How would this assistance integrate with other patient assistance efforts at your practice/clinic?

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* 7. Is there anything else you would like to share with the committee that will assist in evaluating your application?

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* 8. How did you hear about this opportunity?

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* 9. Attestation: I attest that the information contained in this application is true and that I will ensure the gift cards are distributed for the intended purpose.

Yes

Cancer Community Support Grocery/Gas Card Application

Question Title

* 1. Applicant Contact Information:Please list the site "champion" who will accept responsibility for this program.

Question Title

* 2. Approximately how many patients does your site/clinic serve each month?

Question Title

* 3. Describe the infrastructure your organization has in place to efficiently and accountably distribute cards to patients in need. Please include details about how you track card distribution.

Question Title

* 4. Please specify the number of cards requested in each category and the vendor from whom you'd like the gift cards purchased. A maximum of 120 gift cards total will be awarded per eligible practice until funding is exhausted.

Question Title

* 5. Are you receiving funding from other charitable entities to support similar activities?

Question Title

* 6. How would this assistance integrate with other patient assistance efforts at your practice/clinic?

Question Title

* 7. Is there anything else you would like to share with the committee that will assist in evaluating your application?

Question Title

* 8. How did you hear about this opportunity?

Question Title

* 9. Attestation: I attest that the information contained in this application is true and that I will ensure the gift cards are distributed for the intended purpose.

Question Title

* 10. Signature (enter initials)

* 1. Applicant Contact Information:
Please list the site "champion" who will accept responsibility for this program.

* 4. Please specify the number of cards requested in each category and the vendor from whom you'd like the gift cards purchased.
A maximum of 120 gift cards total will be awarded per eligible practice until funding is exhausted.