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Financial Assistance Application

Our hearts are with your family during this unimaginable time. We understand that no amount of financial assistance can ease the pain of losing a child. The purpose of this application is simply to help relieve some of the financial burden so your family can focus on honoring your child's life. Please know that you are not alone.  

Child Information
Current Treatment Status
Newly Diagnosed
Active Treatment
Remission
Relapse
Hospice
Bereavement
Parent/Guardian Information
Home Address
Household Information
Assistance Requested
Please indicate what assistance you are requesting.
Supporting Documentation

Please attach copies of the following, if available:

  • Physician verification or diagnosis documentation

  • Treatment schedule (if applicable)

  • Invoice, estimate, or bill related to the request

  • Hotel receipt, utility bill, funeral invoice, travel estimate, etc.

Have you previously received assistance from the Rylan Strong Network?
Yes
No
Payment Information
Who will receive the payment

I certify that the information provided in this application is true and accurate to the best of my knowledge.

I understand that submitting an application does not guarantee financial assistance.

I understand that assistance is dependent upon available funding and approval by the Rylan Strong Network Board of Directors.

I authorize the Rylan Strong Network to verify information provided in this application, including contacting the funeral home or medical providers when necessary.

I authorize the Rylan Strong Network to use images in social media, marketing, etc. 

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