Hope Family Application

Are you or do you know a family currently experiencing the setbacks that come with fighting pediatric cancer or blood disorders? Please fill out the form below to let us know how we can best help. PLEASE NOTE: We currently have a 2-4 week waitlist as we are receiving new applications every single day. We will get back to you as soon as we can!

Who we help.

Lighthouse for Hope provides assistance for families who have a child with cancer or blood disorder. Lighthouse caters to each families specific needs. Please take the time to fill out the form and let us know how we can best help.

Name

First Name

Last Name

Who is filling out this application?

Have you received assistance from Lighthouse before?

Yes

City, State

Child/patient's Name

First Name

Last Name

Child/patient Age

Diagnosis

Social Worker Name and Email

Hospital

Patient Clothing Size

Email Address

What is your story? Please include details on diagnosis and your family journey so far:

What are your financial needs? For example, what has been the hardest setback?

Where do you prefer to do your shopping? (Target, Walmart, etc.)

What is the best way Lighthouse can help you right now? For example, do you need help paying for gas? Does your child need school supplies? Do you need help with Christmas presents? Please be specific.

At Lighthouse, we would like to share your child's story. Please check the box allowing us to post about your child on our social media platforms.

I give permission for Lighthouse to share on social media.

Social Media

Facebook support page, Instagram, Caringbridge, blog, etc.

Address

If you are not local to Phoenix, please provide a good shipping address.

Family Application

Hope Family Application

Who we help.

hello@lighthouseforhope.org

Lighthouse For Hope 2024