Relief Program Application 2023

Please fill out the form below, make sure to answer all questions.
Applicants must be residents of Utah.
Patient must be in active cancer treatment.
Total amount not to exceed $500 of requested assistance. 

Relief Program Application
What type of treatment are you receiving? (Please mark appropriate treatments)
WE WILL NOT COVER MEDICAL RELATED EXPENSES. YOUR APPLICATION MAY BE REVOKED IF YOU ASK FOR FINANCIAL ASSISTANCE FOR MEDICATION OR OTHER MEDICAL COSTS ASSOCIATED WITH TREATMENT.