2025 Bridge to Wellness | The Journey Fund

Applicant Details

Name

First

Last

If applicant is a minor, please provide parent/guardian name and phone number:

Email

Phone

Address

Address Line 1

Address Line 2

City

State

Zip Code

Date of Birth

Sex

Female
Male
Other

English speaking?

Yes
No

If no, please list language here:

Race/Ethnicity. Please check all that apply:

Monthly Income

Household Size

Primary Cancer

Residence City

Stage

Treatment City

Applicant Need & Supporting Documents

Please briefly explain how this assistance would help you and if it is medically necessary. (You may attach a file if needed or desired).

Letter From Applicant

Click or drag a file to this area to upload.

I am requesting help with:

Copy of Billing Statement(s)

Click or drag a file to this area to upload.

Legal

Authorizations

I give permission for my healthcare representative to release the information disclosed herein to The Journey Fund.
I give The Journey Fund permission to communicate with my healthcare representative regarding this application.
I understand this grant amount will be determined by The Journey Fund.
I give my permission for my photographs, quotes or videotape images to be used for publicity in publications or other media formatted.
I would like to be considered for The Journey Fund Assistance Program Application.

In order for TJF to process this application the applicant must consent to at least the first two authorizations. *** Please note, if you consent to having your photographs, quotes or videotape images to be used for publicity/publications, TJF would contact you directly to obtain photographs/videotape images. This consent does permit us to use quotes from this application in publicity/publications.

Applicant Signature

DISCLAIMER: By typing your name above, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application. I hereby certify that, to the best of my knowledge, the provided information is true and accurate.

Healthcare Representative Information

Name

First

Last

Email

Phone

Facility Name

Role

Verifications

I have verified that this applicant is in active cancer treatment.
I have exhausted all other resources in efforts to find assistance for the applicant.

Healthcare Representative Signature

DISCLAIMER: By typing your name above, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application. I hereby certify that, to the best of my knowledge, the provided information is true and accurate.

*** Please note, applications will be reviewed May 2025. If you have any questions, please email chair of the application committee, Abra Kelson, executivedirector@journeyfund.org.