Indy Foundation

Indy Foundation Logo

Application for Emergency Funds

Who is this request for?

Name of Requestor & Relationship to Cancer Warrior

Requestor's Email

Requestor's Phone Number

Warrior's First Name

Warrior's Last Name

Warrior's Phone Number

Warrior's Email

Warrior's Address

City

State

Zip

Type of Cancer

Treatment Center/Name of Oncologist

Type of Gift Card Requested

Requested Amount

Tell us about your cancer journey.

255 character limit

0 / 255

Has this cancer diagnosis created job loss, travel requirements, extended stays, etc?

255 character limit

0 / 255

How would this gift card help you and your family?

255 character limit

0 / 255

If you are making this request for someone, have they been notified of the request?

How did you hear about us?

**Please note, we get multiple requests per day, we do our best with the limited funds we have. There is a max allocation per month. Funds will be allocated in the order they are recieved. Warriors are eligible once per calendar year.