Financial Assistance Application
**Please allow at least 90 days for approval**
Nicholas E. Colleluori Financial Grant Assistance Program Application
To apply, please carefully read and follow steps 1-6.
- Grant Amounts: Up to $2,000.00 (subject to availability of funds, grants are awarded one-time per applicant. Renewals will not be accepted.)
- Eligibility Requirements: Grant recipients must meet the following eligibility requirements:
- Undergoing treatment at time of application for leukemia, lymphoma or myeloma
- Experiencing financial hardship as a result of medical condition
- U.S. citizens
- Referrals: Grant applications are only considered for applicants who are initially referred by a health professional (e.g., physician, nurse, or oncology social worker) familiar with the applicant’s medical condition and course of treatment. All communications with the HEADstrong Foundation regarding grants or grant applications will be with the referring healthcare professional, and not with the patient.
- Application: Prospective grant recipients must submit a completed Application in the form attached. The Application also requires a referral by a health professional (e.g., physician, nurse, or oncology social worker) familiar with the applicant’s medical condition and course of treatment. Applicants must also certify they are eligible for a grant, according to these guidelines. Applications are reviewed monthly and are only accepted via mail to HEADstrong Foundation 232 Green Avenue Holmes, PA 19043.
- Payments: Payments will be made to the patient in his/her name only, except where the patient is a minor, in which case payment will be made to the patient’s parent or legal guardian.
- Download Application