Financial Assistance Application
Financial Assistance is available for patients currently undergoing active colorectal cancer treatment. Applicants previously awarded funding through this program are not eligible.
Is the applicant currently undergoing active treatment for colorectal cancer?
To be eligible for assistance, the patient must currently be in active treatment for colorectal cancer.
Has the applicant previously received funding from the Alliance’s financial assistance funds, also known as the "Blue Hope" or "Blue Note"?
Patients are only eligible to receive a financial award once. If you have already received an award from the Colorectal Cancer Alliance but still are in need of financial assistance, please check out our
Financial Assistance Guide
and call our Helpline for support with these resources from our certified patient & family navigators: 877-422-2030.
Please also note that if you are not selected to receive a financial award during this application month, you are allowed to reapply
Applicants must live in the United States or a US Territory. US citizenship is not required.
Applicants must have pre-tax household income at or below 300% of the Federal Poverty Line (FPL)
Please provide information about the patient's cancer diagnosis and the current treatment plan.
Type of Cancer
Date of Diagnosis
Current Stage of Cancer
Describe Treatment Plan
Cancer Center Name
Cancer Center Phone Number
Patient First Name
Patient Last Name
Patient Mailing Address
This is the address where the funding will be sent
Patient Zip Code
Patient Phone Number (best contact number)
Patient Email Address
Email address required. MUST be a valid email address as this will inform applicant of approval or denial.
Confirm Email Address
Patient Date of Birth
enter as MM/DD/YYYY
Prefer Not to Answer
Black or African American
Native American/Alaska Native
Native Hawaiian or Other Pacific Islander
Multiracial (two or more races)
If other, please specify
How did you hear about our Financial Assistance Program?
Patient Advocacy Organization
If other, please describe:
Does the patient have medical insurance?
oes the patient have secondary or additional medical coverage?
Other (please specify):
If other, please describe:
Number of people in household
5 or more
What is your current total annual household income?
$0 - $4,999
$5,000 - $9,999
$10,000 - $14,999
$15,000 - $19,999
$20,000 - $24,999
$25,000 - $29,999
$30,000 - $39,999
$40,000 - $49,999
$50,000 - $59,999
$60,000 - $69,999
$70,000 and up
Are you willing to provide proof of income?
If awarded, what expenses will you pay for using these funds?
(check all that apply)
Transportation costs (gas, etc.)
Please tell us how this award will help you or your family during your cancer treatment?
I, the named Applicant, attest and certify, under penalty of law to the Colorectal Cancer Alliance and the agents lawfully acting on its behalf, that the information provided in my application is complete and accurate. I understand that reported financial information may be verified by an audit, as deemed necessary by the Colorectal Cancer Alliance. I further understand that any false or incomplete information provided by me in this application could unduly harm the Colorectal Cancer Alliance, its reputation and its tax exemption status and, therefore, may also constitute fraud for which I may be legally liable. I also understand that, if I am approved for assistance by the Colorectal Cancer Alliance, assistance will terminate and the Colorectal Cancer Alliance may recoup the amount of any financial assistance provided to me if the Colorectal Cancer Alliance becomes aware of any inaccurate information or fraudulent activity relating to my application or the assistance provided to me by the Colorectal Cancer Alliance. Finally, I understand that I am not guaranteed or promised assistance, and that any assistance the Colorectal Cancer Alliance may provide is limited to the terms and conditions established by the Colorectal Cancer Alliance and that the Colorectal Cancer Alliance reserves the right at any time and for any reason, without notice, to: (i) modify this application form, (ii) modify or discontinue any assistance provided by the Colorectal Cancer Alliance or the Colorectal Cancer Alliance’s eligibility criteria or (iii) terminate assistance.
By submitting this application, you grant the Alliance and its successors and licensees and assign unlimited rights to share your story. If awarded, the Alliance may contact you to conduct an interview.
By submitting this application, you grant the Alliance and its successors and licensees and assign unlimited rights to share your story.
Yes, I want to receive email updates from the Colorectal Cancer Alliance.
Yes, I want to receive periodic text updates from the Colorectal Cancer Alliance. Message and data rates may apply. Text STOP to opt out, HELP for info.