HEADstrong Foundation

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Financial Assistance Application

Please note - Here at HEADstrong, we get so many requests to help on a daily basis and while we wish we could financially help each and every one of them we are not able. For this reason, we have limited our financial aid only to those battling a blood cancer such as lymphoma or leukemia.

For those battling another type of cancer, we offer the option to receive a comfort kit, start a relief fund, or join our HEADtoHEAD peer support program.

Comfort kits are sent out on a weekly basis.

Funding for blood cancer patients, applications  are reviewed and awarded monthly based on availability of funds. Because of the large number of applications, only those awarded funding will be notified. 

Keep fighting!

For questions, please email support@headstrong.org

INCOMPLETE APPLICATIONS WILL NOT BE CONSIDERED

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Even though you aren't eligible for our financial aid, we still want to be able to help. We have 2 options you are able to sign up for. Please visit the corresponding link to fill out the form.
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Contact Information
Contact Information Copy
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First Name
Last Name
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Address Line 1
Address Line 2
City
State/Province
ZIP/Postal Code
Country
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(mm/dd/yyyy)
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Do not include dashes. Complete 9 digit SS# is needed.
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Enter numbers only, do not include $, commas or spaces
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Please upload a document to verify your Annual Household Income. This can be a 1040, paystub or current tax return.
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(mm/dd/yyyy)
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Treating Physician Information
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Prefix
First Name
Last Name
Suffix
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Address Line 1
Address Line 2
City
State/Province
ZIP/Postal Code
Country
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By clicking this button, you authorize HEADstrong Foundation to contact your medical team to validate this application.
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Electronic Certification
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The undersigned certifies to HF that he/she meets the eligibility requirements of the Fighter/Relief Program, as described in this Application, and that all the information provide in or with this Application is true and correct.