Important: Washington State Patients ONLY

Our financial assistance programs are available only to eligible cancer patients who receive treatment OR live in the South Puget Sound region of Washington State.
For questions, please refer to our eligbility criteria.

Applicant Details

Name
Address
To help reduce the risk of lost or stolen gift cards, all gift cards and other mailed assistance must be sent either: Directly to the patient’s personal mailing address, or to the cancer care center where the application is being submitted for patient pickup. * We will no longer be able to send gift cards or assistance mail to friends, relatives, or other third-party addresses.
Date of Birth
Sex
English speaking?
Race/Ethnicity. Please check all that apply:

Applicant Need & Supporting Documents

Drag & Drop Files, Choose Files to Upload
Please note that The Journey Fund does not provide checks or Visa gift cards to applicants or pay medical bills. You can request a gift card for groceries or other basic needs or assistance paying a bill for non-medical expenses. ***If you request help with a bill, you must attach the bill to this application for payment.
Gas/Grocery Gift Card (Please Select One)
Drag & Drop Files, Choose Files to Upload

Legal

Authorizations
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.
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
Verifications
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, your application will be reviewed within 30 days of the submission date. If you have any questions, please email chair of the application commiteee, Donna Banks, dbanks@nwmsonline.com.

Our typical processing and mailing turnaround time is 7–10 business days. If a gift card is undeliverable, it is usually returned to our PO Box within 30 days.

If a patient has not received their gift card, we ask that you contact us within 30 days of the application submission so we can investigate and help resolve the issue. After that timeframe, it becomes much more difficult to track or recover returned mail and we will not be able to further help.