Help for Families in Need

Apply for a Grant

What expenses can grant money be used for?

Grant money may be used to cover the costs of temporary lodging while the child undergoes treatment, child care expenditures, transportation costs, lost wages, rent/mortgage payments, utilities, child care and more.

Required Documentation

*Note: To ensure your privacy, please see the notes below on redacting (blocking out) personal account information on any documentation supplied.

Please submit these online:

1. A completed and signed Msgr. Russ Kohler Children's Cancer Endowment Fund Application Form (below; electronic signature accepted)
   Note: Please gather all your information for the application ahead of filling out the form. You will not be able to save your entries and return to the application once you close your browser window.
2. A clear current digital photo (no photocopies or faxed copies) of the child (Upload photo with application). (By submitting a photo, you agree that the photo may be used in marketing/fund-raising materials (print, online, email or other uses) for the Endowment Fund. To ensure the privacy of the child, images will not be identified using full names or personal identifying information without written approval from the photographed subject, parent or guardian.

To ensure your privacy, please send these by mail:

1. A letter summarizing your current financial situation/hardship.
2. A letter from the treating physician and/or social worker on his/her letterhead stating:
   A) the type of cancer diagnosed;
   B) the treatment prescribed; and
   C) a statement that the patient is currently in active treatment. Please be sure to inform the medical professional that we will be contacting them.
3. Most recent pay stub for Applicant (and their Spouse, if applicable)* (Redact first 5 digits of Social Security Number)
4. (2) most recent bank statements for checking and savings accounts* (Redact Account Number)
5. (2) most recent investment account statements* (Redact Account Number)
6. A copy of Applicant's most recent W-2 and Tax Return* (Redact first 5 digits of Social Security Number)
7. Copies of any specific bills that you need help paying (utility bills, mortgage coupon, invoice for temporary lodging, car repair estimate, child care, etc.)
8. A completed and signed Authorization for Release of Protected Health Information Form (download PDF) as required by the HIPAA Privacy Rules. Note that the 60-day expiration may be changed to any amount of time by the patient/family, if more time is needed to get the necessary documentation.

Applications submitted WITHOUT the required elements WILL NOT BE CONSIDERED.

Please mail additional required documentation to:
Msgr. Russ Kohler Children's Cancer Endowment Fund
c/o STAT Patients Family Services
P.O. Box 63
Newport, MI 48166

Permission to Share Your Personal Information

All applications are kept confidential.

By submitting your grant application to the Msgr. Russ Kohler Children's Cancer Endowment Fund, we reserve the right and you (the applicant) hereby grant permission to share all information provided by the applicant to third parties (including your doctor or social worker) on an as‑needed basis.

Important: Please have all your information ready before you begin filling out the form below. The form must be completed and submitted in a single session; you cannot save your information to return and complete the form in another session.

Optional: If you prefer to submit your application by mail, please download the PDF Application Form. See Instructions for completing the form in Adobe Acrobat Reader or you may print the form and fill it out by hand.