Kelllie's Krew Patient Assistance Application
  • Kellie's Krew is dedicated to helping patients with ACC, Head and Neck Cancer, as well as Osteosarcoma with our Gift Card Program given to any patient with qualifying diagnosis and our Patient Assistance Grant for those whom have a long term reocurrant diagnosis. If you would like to download and print this application, please click HERE
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  • Identification
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  • First Name*
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  • Last Name*
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  • Street Address*
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  • City*
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  • State*
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  • Zip*
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  • Home Phone*
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  • Cell Phone*
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  • Business Phone*
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  • Email*a valid email address
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  • Best Contact Method*Please select one
    Phone
    Post
    Email
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  • Personal Information
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  • Marital Status*
    Single
    Divorced
    Partnered
    Married
    Separated
    Widowed
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  • Employment & Financial Information
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  • Employment*Have you lost time from your place of employment?
    Yes
    No
    Unemployed
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  • If "Yes" selected*Please give additional and specific details of how much time has been lost, dates of lost work, and dates of last employment
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  • Current Financial Obligations*Select One or More
    Children Under The Age of 18 In Home
    Mortgage
    Rent
    Credit Debt
    Tuition
    Vehicle Loan
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  • Other Financial Obligations*Any major financial obligations not listed above
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  • Caregiver Information
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  • Primary Caregiver*Full Name
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  • Caregiver Relationship*select one
    Spouse/Partner
    Child
    Friend
    Medical Professional
    Other
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  • Cancer History
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  • Medical History*Please tell us about your cancer medical history. Include primary diagnosis, locations, origin of tumor, and dates. Please be as specific as possible
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  • Metastasization*Has your cancer metastasized?
    Yes
    No
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  • If, YES, where?*
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  • Previous Treatment*Please identify treatment facilities, chemotherapies, drug regimen, and/or number of radiation treatments.
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  • Future Treatment*Please identify treatment facilities, chemotherapies, drug regimen, and/or number of radiation treatments.
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  • Number of Outpatient Visits*Last 12 Months
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  • Number of InPatient Days*Last 12 Months
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  • Number of Hospitalizations*Last 12 Months
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  • Distance Driven For Treatment*From home
    0-50 Miles
    51-100 Miles
    101-150 Miles
    Over 150 Miles
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  • Additional Information
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  • Comments*Is there anything else that you would like to share?
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  • Kellie’s Krew, Inc. strives to help as many applicants as possible from the funds raised through our events and donors.

    Please be aware of the following guidelines when applying for assistance from Kellie’s Krew:

    • ELIGIBILITY FOR ASSISTANCE IS LIMITED TO PATIENTS WITH ACC, HEAD & NECK CANCERS, AND OSTEOSARCOMA. PRIORITY IS GIVEN TO PATIENTS WITH METASTASIZATION. • All applicants must be undergoing treatment at the time of and during the month of requested assistance. • Applications must be submitted on or before the 15th of each month to be considered for assistance in the following month. • Each applicant is limited to one (1) Patient Assistance Grant. You may reapply for the Gift Card Program. • All applicants for long term patient assistance must have a long term recurrent diagnosis and undergoing treatment at the time of requested assistance. • Applications must be submitted on or before the 15th of each month to be considered for assistance in the following month. • Applicants are limited to one (1) long term patient assistance grant per lifetime. • The Kellie’s Krew Patient Assistance Program is limited to $5,000 and will be provided by certified check, as well as reported to the IRS on a form 1099. • The Kellie’s Krew Board of Director’s reserves the right to deny applications based upon funds availability, or other circumstances that may arise. • Kellie’s Krew Inc., does not discriminate against any person on the basis of race, color, national origin, disability, gender, gender identity, sexual orientation, religious preference, or age in its programs, services, assistance programs and activities. • We value your privacy, therefore applicant information and medical history will only be shared with the Kellie’s Krew Board of Directors unless prior consent is obtained.
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  • Prior to clicking "Submit", please email a recent picture of the applicant with the file name including the name of the applicant (Ex. janedoe.jpeg) to pictures@kellieskrew.com

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  • Affirmation & Agreement*By selecting "yes" you are agreeing to the terms and conditions as outlined above. You are also agreeing that the information you have submitted is true. Your acceptance of the Short Term Patient Assistance Terms and Conditions by clicking "yes" or "no" is valid as an electronic signature per U.S. Federal guidelines.
    Yes
    No
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