Individual Grant Application

Thank you for taking the time to complete this grant application form.  The team from Steph’s Wild Ride has worked to make this application as simple as possible. Please carefully read and understand the eligibility requirements.

Our goal is to find patients who are receiving treatment and need financial assistance. Money will be given in the form of gift card to desired locations (I.E. shopping centers, pharmacy’s, and gas stations) up to $1000.00. This is a non-profit contribution. We are working for you in honor of Stephanie Micka who lost her battle with cancer the summer of 2007.

Eligibility requirements:
1. You must be under the age of 21
2. You must be diagnosed with some form of cancer
3. You must currently be receiving medical treatment
4. You must be a resident of Massachusetts

Our goal here at Steph’s Wild Ride is to carry on Stephanie’s name through donations raised to help people like you who are going through cancer treatments. Our hearts go out to all people in the past, present, and future cancer victims.

I look forward to hearing from all of you,
Jessica Faszcza
Grants Coordinator

Applicant's Information

Your Name (required)

Name of Person Completing Application (If different from Applicant)

Your Email (required)

Address

Telephone:

Medical Information

Type of Cancer

Date of Diagnosis

Currently Receiving Treatment?
YesNo

If yes, where?

Financial Need

Need for Funding: (Please explain what you plan to do with any money awarded):

Amount of Monies being requested:

How did you hear about us?

If grant monies are awarded, I agree to have a follow-up interview and have quotes from that interview posted on the Steph’s Wild Ride website:
YesNo

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