Apply Online – Northwest Kansas Foundation for Hope

The online grant application is an excellent tool to help you manage your application and award information right from our website. These few tips will help your experience go very smoothly:

Secure all of your supporting documentation before beginning the application and scan to your computer, saving it in a location you will remember. You will be asked to upload these items before you begin filling in the application. Those items are as follows:

– A letter from Physician or Qualified Medical Representative to confirm diagnoses of Cancer and type of treatment needed.
– A listing of expenses, real or projected, for which the grant is being requested.
– A timetable for expenditures.

You are required to print, complete and sign the ‘Authorization to Release and/or Receive Confidential Information’ form and upload as part of your supporting documentation. You will also use this to secure a letter from your physician’s office. Please access the document click AUTHORIZATION FORM.

The members of the Foundation highly value and are committed to your privacy and security. The information you provide is sent to a secure e-mail address of the Foundation grants committee and is reviewed only by the grants committee. Please feel free to complete the application by hand by downloading the paper form PAPER APPLICATION.

If at any time you have questions or concerns, please CONTACT US.

File Upload Center

Confirmation of Diagnosis Letter *
Listing of Expenses *
Expenditure Timetable *
Confidential Information Authorization *

Patient Information

Today's Date *
Name *
Date of Birth *
Address *
Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry
Phone (Daytime) *
Phone (Evening) *
Phone (Cell) *
Email *

Applicant/Contact Person (if different from patient)

Name
Date of Birth
Address
Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry
Phone (Primary)
Email

Preferred Distribution of Grant Monies

Due to our non-profit status, we cannot make checks payable to recipient.

Option #1: Allocation of Funding Option
If you would like to allocate your funding among various expenses, please make that designation below. Please use the following sample format: EX 1: $500 to Citizen's Medical Center for medical bills EX 2: $500 to Visa Gift Card for travel expenses
Option #2: Full Grant Distribution Options:
Visa Gift CardDillon's Gift CardCheck Made Payable (Please select your designee below)
Check Designee
If you would like us to mail a check on your behalf, please type in your designee below. Examples include: Pharmacy, Doctor's Office, Hotel/Motel

Electronic Signature

E-Signature Agreement By selecting the "I Accept" button, you are signing this Agreement electronically. You agree your electronic signature is the legal equivalent of your manual signature on this Agreement. By selecting "I Accept" you consent to be legally bound by this Agreement's terms and conditions. You further agree that your use of a key pad, mouse or other device to select an item, button, icon or similar act/action, or to otherwise provide NWKS Foundation for Hope, or in accessing or making any transaction regarding any agreement, acknowledgement, consent terms, disclosures or conditions constitutes your signature (hereafter referred to as "E-Signature"), acceptance and agreement as if actually signed by you in writing. You also agree that no certification authority or other third party verification is necessary to validate your E-Signature and that the lack of such certification or third party verification will not in any way affect the enforceability of your E-Signature or any resulting contract between you and NWKS Foundation for Hope.
Date *
Name *

Verification

Please enter any two digits *Example: 12
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