Ishan Gala Foundation

Financial Assistance Request

* First Name

* Last Name

* Email

* Child's Full Name

* What stage of treatment are you currently in?

* Please provide us with any updates about your child , where you are in treatment and any details pertaining to the financial request.

* What are you requesting financial assistance for?

* What is the amount you are requesting? (If requesting help with multiple items please provide the total for each one)

Please provide Company Name for the bill, Company Phone Number, and any account numbers or information needed to pay the bill

If requesting Gas or Grocery Gift cards, please provide store or gas station near you

If requesting gift cards, please provide mailing address

Please upload a picture and/or document of the bill(s) you are requesting assistance for:

Image

* If approved may we share any updated information provided above? *This is very important to keep our programs going and growing to help you and more families like you*

* If approved may we share how we helped your family with this request? *This is very important to keep our programs going and growing to help you and more families like you*

If you would like to share any updated photos for us to share please upload here

Photo

If you are completing this form on the behalf of a family please provide your name and contact information

Financial Assistance Request

*Please make sure you have completed our initial registration form before submitting a financial request*

Financial requests can be submitted by families who have completed our initial registration request form and have been verified by us as a family in need.

Eligibility:

Must have a child diagnosed with cancer under the age of 18

Must be verified by the social worker at treatment hospital as in need of financial assistance