Ishan Gala Foundation

New Family Registration- For families outside of Virginia

* First Name

* Last Name

* Email

* Address

* City

* State

* Postal Code

* Mobile Phone

* Marital Status

* Are you currently employed?

* Monthly Household income

Parent 2 (If applicable)

P2 First Name

P2 Last Name

P2 Email

P2 Phone Number

P2 Address (If different)

Can we contact them if you are unreachable?

Diagnosed Child's Information

* Child's First name

* Child's Last Name

* Date of Birth

* Diagnosis

* Diagnosis Date

* Primary Hospital for treatment

* Social worker name

* Social Worker Email

* Social Worker Phone Number

* What current stage of treatment are you in?

If in maintenance phase, please provide the date maintenance began and when the expected finish date is

If completed Treatment, please provide month and year treatment was completed

If finished treatment, please provide information about major health issues due to treatment

* Your Journey so far

Please tell us about any urgent financial assistance you have right now needs

Privacy and Sharing

Allowing us to share your story and pictures helps us raise funding for our programs and awareness about the fight against childhood cancer. It is not required to allow us to share to qualify for our services.

* May we share your story?

* May we share pictures of your child fighting? (please select sources you are ok with us taking pictures from)

* May we share pictures of your whole family?

* May we share first names in our stories and with pictures?

Caring Bridge link

Facebook Page

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

* How many children 18 or under in your household?

The Ishan Gala foundation is here to welcome you into their family to support you through this long, unpredictable journey.

Currently, We are only able to offer our financial assistance program to families that live outside of the state of Virginia.

Our financial assistance program help families with bills at home, costs associated with treatment including travel expenses, meals, grocery gift cards and any other essential needs. We pay the bills directly to the company, provide gift cards or purchase items to be shipped directly to the family. We do not give cash or checks directly.

If you have any questions please feel free to reach out to us at 434-234-4644 or ashley@ishangala.org