HEADstrong Foundation

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Comfort Kit Requests

Please fill out the form to request a comfort kit be sent out. Our comfort kits are sent out on a weekly basis and include items we have found helpful for those going through cancer treatment. Because of the large number of requests, we are only able to offer 1 kit per patient.

Have you received a comfort kit from HF in the past? *

Yes

We Are Sorry But You Do not Qualify

Since you have already received a kit from us, you do not qualify for another kit. We wish you the best as you continue on your fight.

Do you live in the United States *

Yes

We Are Sorry But You Do not Qualify

Since you do not live within the United States, you do not qualify for a kit as we are unable to send kits outside of the US. We wish you the best as you continue on your fight.

Are you currently receiving active cancer treatments? *

Ex. Chemo, Radiation, Transplant, CAR-T Therapy

Yes

We Are Sorry But You Do not Qualify

Since you are not receiving active treatments, you do not qualify for a kit. We wish you the best as you continue on your fight.

How did you hear of HEADstrong Foundation? *

Contact Information

Name *

First Name

Last Name

Email *

Verify Email *

Address *

Address Line 1

Address Line 2

City

State

State/Province

ZIP/Postal Code

Phone *

Date of Birth *

(mm/dd/yyyy)

Type of Cancer *

Date of Diagnosis *

(mm/dd/yyyy)

Gender *

Male

Female

Non-specific

Treating Physician Information

Hospital Where Receiving Treatment *

Treating Physician Name *

Prefix

First Name

Last Name

Suffix

Physician Address *

Address Line 1

Address Line 2

City

State

State/Province

ZIP/Postal Code

Country

Physician Phone # *

Are you willing to share your story with us and our supporters?

We love to share patient/caregiver stories with our supporters so we can continue to help as many cancer patients as possible. If you are willing, please email a picture with your new kit, contact info and your story to us at HFsupport@headstrong.org and we will share with our marketing team.

Yes! Absolutely!

No, I am not comfortable with sharing.

Electronic Certification

The undersigned certifies the below *

The undersigned certifies to HF that he/she/they 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.

I agree