Financial Assistance – The Ellie Ruby Foundation

Please complete the form in its entirety. If you have any questions, please email us by clicking here

Guardian Information

Parent Guardian I
The Ellie Ruby Foundation will use the contact information provided in this section to update the family on the status of this application

NAME*

First Last

RELATIONSHIP TO PATIENT*

Mother

Father

Grandparent

Other

DOB*

EMAIL*

PHONE*

OCCUPATION*

ADDRESS*

Please provide address where payment should be mailed

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

PARENT GUARDIAN II (IF APPLICABLE)

NAME

First Last

RELATIONSHIP TO PATIENT

Mother

Father

Grandparent

Other

DOB

PHONE

OCCUPATION

APPROXIMATE HOUSEHOLD INCOME*

Hospital Information

HOSPITAL NAME

ADDRESS*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

PRIMARY ONCOLOGIST*

First Last

PHONE*

EMAIL*

SOCIAL WORKER*

Please notify your social worker that a representative of The Ellie Ruby Foundation will be reaching out to discuss your application

First Last

PHONE*

EMAIL*

Request Detail

HOW DO YOU INTEND TO USE THE FUNDS YOU'RE APPLYING FOR?*

Financial assistance is provided to help alleviate the financial pressures of a pediatric cancer diagnosis and provide families with additional funds to spend quality time making memories with their loved ones. You have discretion to use the funds in a way that maximizes your benefit, provided they are used in a way to enhance the life of the patient.

AMOUNT REQUESTED*

Please enter a number greater than or equal to 0.

HAVE YOU PREVIOUSLY APPLIED FOR FINANCIAL ASSISTANCE THROUGH THE ELLIE RUBY FOUNDATION?*

PLEASE LIST THE NAME(S) OF ANY OTHER ORGANIZATIONS YOU HAVE ALREADY RECEIVED OR ARE SEEKING FINANCIAL ASSISTANCE FROM

HOW DID YOU HEAR OF OUR ORGANIZATION?*

Social Media

Friend / Family

Social Worker

Other

Terms and Conditions

I understand that it is in the sole discretion of The Ellie Ruby Foundation to determine if and what level of financial assistance may be provided.
I represent that I am authorized to submit this application on behalf of the patient and family and certify that the information I have provided is true and correct to the best of my knowledge. I understand that any false statements or deliberate omissions on this application may disqualify me from receiving financial assistance.
I hereby grant permission to The Ellie Ruby Foundation to use the provided digital images/videos of my child/family on its platform, including but not limited to its website, social media, and any of its marketing materials and communications. I agree and consent that the names and identities of my family may be revealed by descriptive text or commentary. I further acknowledge and agree that there will be no financial or other remuneration for either the initial or subsequent use of these photos/videos. This authorization shall continue until terminated in writing.

I have read and agree to the terms and conditions

Yes

SIGNATURE*

Please enter first and last name of person filling out form

RELATIONSHIP TO PARENT*

Parent

Grandparent

Social Worker

Other

This field is for validation purposes and should be left unchanged.

Financial Assistance Application

Guardian Information

Family Information

Patient Information

Hospital Information

Request Detail

Terms and Conditions