Shelinsky Strong Foundation

Please Donate

Criteria

1. Patient must reside in PA, NJ, or DE.
2. Patient must be diagnosed with a terminal (incurable) illness.
3. Patient’s household income must be no more than 700% of federal government’s poverty level.
4. Patient must be receiving treatment for the diagnosis at the time the board votes on the application.
5. Patient must be living at the time the board votes on the application.
6. Patient must demonstrate household financial hardship due to diagnosis.

In order to qualify for financial assistance, the above criteria must be met. If you feel you meet the criteria, please fill out the information below and send to shelinskystrongfoundation@gmail.com. Please note that patients may only receive financial support from the organization once in a calendar year.

Name *

First

Last

Email *

Address:

Date of Birth:

Referred by:

Physician Name: *

Physician Phone number:

Diagnosis: *

Date of Diagnosis: *

Treatment Center: *

Marital Status

• Single
• Married

Are you currently employed? If so, please list employer.

Children Dependents:

Expenses (monthly): *

Mortgage/Rent: Student Loans: Utilities: Treatment/Medical Related: Other (please specify):

The application process is the Board’s way of getting to know you and your family. It is our way of understanding your need for assistance, so if you are comfortable, please tell us your story and include a photo of yourself and/or family so that we can get to know you!

Submit

*Please provide pathology report and/or a physician letter confirming diagnosis. Failure to do so may result in rejection of application.