Financial Assistance Application

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.

Apply by filling out the online form below. If you would prefer to print out the application and mail it in click HERE for a printable version.

Date

Name of person filling out application

Name of person for whom funding is requested

Age of individual for whom funding is requested

Address

City , NH. Zip

E-mail address

Phone number

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?

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.

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