1. I understand that my application cannot be processed until I have completed all documentation and submitted it to the email/address shown on top of this application.

2. A completely filled out and signed application.

3. A letter from the treating physician and/or social worker on his/her letterhead stating the type of cancer diagnosed, the treatment prescribed and a statement that my child is currently under treatment.

4. A letter from the applicant explaining their situation, need, etc.

5. Supply the most recent pay stub and a copy of the previous calendar years W- 2 tax forms.

6. Applicant must also include supporting documentation (copy of utility bills, mortgage coupon, etc) to support the items checked in the prioritized list above.

7. Applicant must include a clear original photo (no photo copies) of the child diagnosed with cancer. The applicant’s signature below releases the organization (Kids Cancer Alliance and The Lemonade for Life Foundation) and gives permission to publish on our website/newsletter/letter a picture and a small statement from your family.

8. I certify that the information provided is true and correct as of the date set forth opposite my signature and that any intentional misrepresentation of the information contained in this application will result in the loss of current or future assistance and may result in criminal and/or civil liability. The applicant releases the organization from any and all liability which may arise from the sharing of this information with third-parties.

9. I also give the organization permission to publish in print, electronic, and video format the likeness or image of myself, child, and family. I release all claims against the organization (Kids Cancer Alliance and The Lemonade for Life Foundation) with respect to copyright ownership and publication including any claim for compensation related to use of the materials.

Lemonade for Life Financial Assistance

First, let's collect some patient information:

Patient Name

Date of Birth

Diagnosis

Primary Address

Patient Age

Gender

Hospital

Oncologist

Social Worker