Financial Hardship Fund Application Form

To apply for our financial hardship fund please complete the below application form and a member of the team will be in touch.

Currently, our Hardship Fund has a backlog and there is at least a 1-month delay, we advise you to continue to fill in the application form and we will get back to you as soon as possible.

All the below questions are required. If you require any further information please email advocacy@leukaemiacare.org.uk.

Surname:

First name:

Title:

Email address:

Contact telephone number:

Home address:

Gender:

Date of birth:

Are you the patient or family member?
PatientFamily memberOther
If family member, please specify your relationship:

What is the patient’s diagnosis?

What hospital is the patient being treated at? Please provide the name and email of the consultant haematologist treating the patient.

What will you use the grant for?

Hear about how we can support you further

If you wish to hear about our services and how to get involved, please tick the box below:

I am happy to receive email communications/newsletters from Leukaemia Care

Share your story

If you wish to share your story of diagnosis or supporting someone with a blood cancer, please let us know and we will get in touch with you. We use stories to show our impact to supporters but also in campaigning work to improve the lives of people affected by blood cancer.

I would like to share my story

Application agreement

I confirm I have read the terms and conditions and agree to abide by them. I also agree to provide written feedback once I have received the grant.

Name:

Date: