Jim Bashaw Cancer and Catastrophic Illness Fund Application

(Please note: applicant must be a resident of Franklin or Grand Isle County, VT)

Applicant Name*
First Last
Date of Birth*
Month
Day
Year
Gender
- Male
- Female
- Other
Who is completing this form?*
- Applicant
- Other
Permission*
I have obtained the patient's permission to apply on their behalf.
- Yes
- No
Applicant's Email
Home Phone
Work Phone
Applicant's County*
Applicant must be a resident of Franklin or Grand Isle County, VT
Applicant's Town of Residence
If different from mailing address
Mailing Address*
Street Address Address Line 2 City State ZIP Code
Is your mailing address different than your physical address?*
- Yes
- No
Physical Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Do you have health insurance?*
Check the services you use
- Medicare
- Medicaid
- Commercial Insurance
Number of adults you are financially responsible for
Number of children under 18 you are financially responsible for
Please list estimated household monthly income
Total amount requested by applicant*
Please enter a number less than or equal to 500.
Do you have an active/current cancer diagnosis?*
- Yes
- No
Select your cancer diagnosis*
Other type of cancer diagnosis
Describe your catastrophic illness
Who is your treating physician?
May we contact your physician?
- Yes
- No
Explain the need for this grant*
Method of grant distribution*
Specify vendor mailing address & phone number; include name on account and account number*
Specify your need for an onsite distribution*
Is this a first request?
Would you be willing to share with us how this fund has helped you in the past?
- Yes
- No
Share your story
Would you like to receive future notices on fundraising opportunities for the Jim Bashaw Fund?
- Yes, please
- No, thank you
How were you made aware of this fund?
By checking this box, I affirm that all information provided in this application is accurate to the best of my knowledge. I authorize Northwestern Medical Center to verify any given information as needed to determine eligibility.*
- I agree
Please type the name of the person filling out this form, if not applicant
Contact phone number for person filling out form, if not applicant
Email address of person filling out this form, if not applicant
Documentation
Max. file size: 50 MB.
Please upload receipts or invoices for reimbursement.

For more info, please call (802) 524-8913.

We will do our best to process applications quickly, but please note that the committee typically meets the first week of each month and the review process may take up to 30 days.