Northwest Kansas Foundation for HOPE Grants

Northwest Kansas Foundation for HOPE Grants is sponsored by Northwest Kansas Foundation for HOPE. Provides financial assistance to cancer patients in northwest Kansas to help offset expenses related to their diagnosis and treatment.

Apply Online – Northwest Kansas Foundation for Hope The online grant application is an excellent tool to help you manage your application and award information right from our website. These few tips will help your experience go very smoothly: Secure all of your supporting documentation before beginning the application and scan to your computer, saving it in a location you will remember.

You will be asked to upload these items before you begin filling in the application: – A letter from Physician or Qualified Medical Representative to confirm diagnoses of Cancer and type of treatment needed. You are required to print, complete and sign the ‘Authorization to Release and/or Receive Confidential Information’ form and upload as part of your supporting documentation.

You will also use this to secure a letter from your physician’s office. The members of the Foundation highly value and are committed to your privacy and security. The information you provide is sent to a secure e-mail address of the Foundation grants committee and is reviewed only by the grants committee.

Please feel free to complete the application by hand by downloading the paper application . If at any time you have questions or concerns, please contact us . Confirmation of Diagnosis Letter * Confidential Information Authorization * Address * Address (needed to mail awarded grants) Street Address Apt, Suite, Bldg.

(optional) City State / Province / Region Postal / Zip Code Afghanistan Albania Algeria Andorra Angola Antigua and Barbuda Argentina Armenia Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bhutan Bolivia Bosnia and Herzegovina Botswana Brazil Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Central African Republic Chad Chile China Colombia Comoros Congo (Brazzaville) Congo Costa Rica Cote d\'Ivoire Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic East Timor (Timor Timur) Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Fiji Finland France Gabon Gambia, The Georgia Germany Ghana Greece Grenada Guatemala Guinea Guinea-Bissau Guyana Haiti Honduras Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati Korea, North Korea, South Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Mauritania Mauritius Mexico Micronesia Moldova Monaco Mongolia Montenegro Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands New Zealand Nicaragua Niger Nigeria Norway Oman Pakistan Palestinian Territory Palau Panama Papua New Guinea Paraguay Peru Philippines Poland Portugal Qatar Romania Russia Rwanda Saint Kitts and Nevis Saint Lucia Saint Vincent Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa Spain Sri Lanka Sudan Suriname Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Togo Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States of America Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Western Sahara Western Samoa Yemen Zambia Zimbabwe Country Applicant/Contact Person (if different from patient) Address Street Address Apt, Suite, Bldg.

(optional) City State / Province / Region Postal / Zip Code Afghanistan Albania Algeria Andorra Angola Antigua and Barbuda Argentina Armenia Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bhutan Bolivia Bosnia and Herzegovina Botswana Brazil Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Central African Republic Chad Chile China Colombia Comoros Congo (Brazzaville) Congo Costa Rica Cote d\'Ivoire Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic East Timor (Timor Timur) Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Fiji Finland France Gabon Gambia, The Georgia Germany Ghana Greece Grenada Guatemala Guinea Guinea-Bissau Guyana Haiti Honduras Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati Korea, North Korea, South Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Mauritania Mauritius Mexico Micronesia Moldova Monaco Mongolia Montenegro Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands New Zealand Nicaragua Niger Nigeria Norway Oman Pakistan Palestinian Territory Palau Panama Papua New Guinea Paraguay Peru Philippines Poland Portugal Qatar Romania Russia Rwanda Saint Kitts and Nevis Saint Lucia Saint Vincent Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa Spain Sri Lanka Sudan Suriname Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Togo Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States of America Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Western Sahara Western Samoa Yemen Zambia Zimbabwe Country Preferred Distribution of Grant Monies Due to our non-profit status, we cannot make checks payable to recipient.

Option #1: Allocation of Funding Option If you would like to allocate your funding among various expenses, please make that designation below.

Please use the following sample format: EX 1: $500 to Citizen's Medical Center for medical bills EX 2: $500 to Visa Gift Card for travel expenses Option #2: Full Grant Distribution Options: Visa Gift Card Dillon's Gift Card Check Made Payable (Please select your designee below) Check Designee If you would like us to mail a check on your behalf, please type in your designee below.

Examples include: Pharmacy, Doctor's Office, Hotel/Motel E-Signature Agreement By selecting the "I Accept" button, you are signing this Agreement electronically. You agree your electronic signature is the legal equivalent of your manual signature on this Agreement. By selecting "I Accept" you consent to be legally bound by this Agreement's terms and conditions.

You further agree that your use of a key pad, mouse or other device to select an item, button, icon or similar act/action, or to otherwise provide NWKS Foundation for Hope, or in accessing or making any transaction regarding any agreement, acknowledgement, consent terms, disclosures or conditions constitutes your signature (hereafter referred to as "E-Signature"), acceptance and agreement as if actually signed by you in writing.

You also agree that no certification authority or other third party verification is necessary to validate your E-Signature and that the lack of such certification or third party verification will not in any way affect the enforceability of your E-Signature or any resulting contract between you and NWKS Foundation for Hope. Please enter any two digits * Example: 12 This box is for spam protection - <strong>please leave it blank</strong>: