Child Information

Child’s Name:

Child’s Age:

Child’s Date of Birth:

Child’s Gender
FemaleMale

Is the child actively receiving treatment?
YesNo
If no, when did your child last receive treatment?

Child’s Diagnosis & Date of Diagnosis:

Is your child’s treatment being facilitated at a hospital?
YesNo
If yes, which hospital?

Please attach a physician’s form.

Household Size

How many people currently live in your household?
12345+

Does the child have siblings?
YesNo
Please list the name and age of each family member:

Parent’s Information

Parent’s name

Parent’s email

Parent’s phone

Parents complete mailing address

Parent’s social media account URLs

What has been your biggest challenge and need in fighting against childhood cancer?

How did you hear about Leia’s Kids?

Please upload a picture of your warrior here:

Social Worker Name, Email, and Phone Number:

Confidentiality Statement

Your responses to the following questions will not disqualify you from receiving assistance. This information is collected solely for data collection and program expansion purposes. All responses will remain confidential and will not impact your eligibility for assistance.

Household & Financial Information

Military Status

N/AActiveReserveVeteran

Health Insurance

Does your child have health insurance?
YesNo
If yes, which provider?

Household Income

What is your estimated annual household income??
Under $25,000$25,000 – $49,999$50,000 – $74,999$75,000 – $99,999$100,000 – $149,999$150,000+
Estimated Household Income After Diagnosis:

Additional Financial Burdens

Are there other medical needs in your household? (For example, another child undergoing treatment, a family member with a chronic illness, disabilities, neurological conditions such as epilepsy, or any other medically complex needs.)

Are there other financial burdens you would like to share? (e.g., a child in college, single-family income, other major expenses)

Financial Impact of Cancer

Has a cancer diagnosis impacted your household financially?
If so, please describe how (e.g., loss of income, increased medical expenses, caregiving responsibilities, etc.):

Has a parent/caregiver stopped working or reduced hours due to your child’s illness?
YesNoReduced Hours

Financial Assistance

Are you currently receiving any financial assistance? (Check all that apply)
MedicaidSocial Security Disability (SSI/SSDI)Food Stamps/SNAPHousing AssistanceOther Non Profit AssistanceOther
If Other, specify here:

Financial Challenges

Have you faced any of the following financial struggles due to your child’s illness? (Check all that apply)
Difficulty paying rent/mortgageUtility shutoff noticesCar payments or transportation issuesMedical debtBankruptcyEviction riskOther
If Other, specify here:

Grant Use

How do you plan to use this grant? (Check all that apply & explain below)
Medical expenses not covered by insuranceTravel/lodging for treatmentsMortgage/rent assistanceUtilities (electric, water, etc.)Groceries/food supportChildcare for siblingsEducational support (tutors, online schooling, etc.)Other
Additional Explanation (if needed):