Quality of Life Assurance Program

This program provides financial assistance, up to $500.00, for young adult cancer survivors, aged 17-21, who require assistance in meeting their academic or employment goals. Funds can be requested to defray costs of vocational rehabilitation, tutoring, supported employment, or assistive technology devices. Applicants must be residents of the state of New Hampshire, and must file an Application for Family Services with the Lifeline if not already affiliated with the organization.

Financial Assistance Application

Date_________

Name of person filling out application____________________________
Name of person for whom funding is requested_____________________
Age of individual for whom funding is requested_____________________
Address_____________________________________________________
E-mail address_______________________________________________
Phone number in case we need to contact you for further information
__________________ best time to contact ________________________

Is the individual currently enrolled in school?_____________ At what level?________ Where?____________________________________________
What supports are being provided to insure success (tutoring, direct instruction,
program modifications)?_____________________________________________
_________________________________________________________________

Is the individual currently working with Vocational Rehabilitation?_________
If so, in what capacity?_____________________________________________

Is the individual in a supported employment environment?_________________
Where?__________________________________________________________
Please provide a brief description of the job / responsibilities______________
_________________________________________________________________

Please describe the purpose of requested funds _________________________
_________________________________________________________________

How do you hope this assistance will improve the quality of the individual's life?
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________

Please mail completed application to:

Childhood Cancer Lifeline of NH
Attn: Quality of Life Assurance Program
PO Box 395
Hillsboro, NH 03244

Applications for assistance are considered on a monthly basis at the Board of Directors meeting. Amounts allotted are at the discretion of the Board of Directors. Availability of funding, as well as access to other supports will be factors in the determination. All decisions are final.