Family Grant Application Step 1 of 11 9% Have you previously received funding from Runway for Recovery? Yes No I reside in the following state:(Required)CaliforniaConnecticutMaineMassachusettsNew JerseyNew YorkOther At this time you can only receive one family grant. If you need assistance finding other resources, please reach out to our Director of Program, Kathryn Phillips at kathryn@runwayforrecovery.org. Thank you for your interest in Runway for Recovery’s Family Grant program. Unfortunately, our services do not currently cover the area you have indicated the recipient lives in. The Family Grant program currently only covers the six New England states and Orange and L.A. counties in California. Signature(Required)By signing above, I confirm that I am the applicant applying for this family grant. I understand that this application may not be submitted on behalf of another individual. How has breast cancer impacted you? (Runway only funds patients and families where a guardian has passed away from breast cancer or a guardian is living with Stage IV, metastatic breast cancer. We do not fund patients who are stages 0-3). A loved one has passed away from breast cancer I am currently living with Stage IV, metastatic breast cancer Have you previously applied for funding?(Required) Yes No First Name(Required)Last Name(Required)Email Address(Required)Cell Phone(Required)Preferred Name(Required)Preferred Contact MethodEmailPhoneEitherI consent to receive text messages from the Runway for Recovery team. Yes No Family InformationPlease provide information about your family.Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Birthdate(Required)MonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Parent/Guardian 2 First Name(Required)Parent/Guardian 2 Last Name(Required)Parent/Guardian 2 Email(Required)Parent/Guardian 2 Cell Phone(Required)Family's Preferred Language(Required)Please note that Runway for Recovery does not have an interpreter on staff. If one can be provided during the application process, especially for the 360-review, our Care Team will be happy to continue working with the family.Are there children living at home?(Required) Yes No Child/Children InformationIf there are children in the household, please provide us information below.Child First Name(Required)Child Last Name(Required)Child 1 Birthdate(Required)MonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Is there another child? Yes No Child 2 First Name(Required)Child 2 Last Name(Required)Child 2 Birthdate(Required)MonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Is there another child? Yes No Child 3 First Name(Required)Child 3 Last Name(Required)Child 3 Birthdate(Required)MonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Please list any additional members of the family's householdHas the child/children experienced any other family members going through cancer and/or deaths? If yes, please explain who and when. Cancer Diagnosis InformationDate of Cancer Diagnosis(Required)MonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Please provide the name of the primary oncologist(Required)Does Runway have permission to contact the oncologist?(Required) Yes No At which hospital/clinic is/was treatment being received?(Required)Please upload a letter from your doctor detailing your stage IV breast cancer diagnosis and treatment.(Required)Max. file size: 50 MB. Social Worker/Patient Navigator Name(Required)Social Worker/Patient Navigator Email(Required)Does Runway have permission to contact the social worker/patient navigator?(Required) Yes No Loved One InformationPlease provide information about the loved one who has passed.First Name(Required)Last Name(Required)Date of Passing(Required)MonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Age of Passing(Required)Where did they receive treatment before their passing?(Required)Please explain the diagnosis(Required)If there were children at home, what was the relationship of the loved one to the child/children? What age(s) were they when the loved one passed? Cancer's ImpactHow has your cancer diagnosis impacted your family?(Required)How has the loss of your loved one impacted your family?(Required)What issues have the family experienced since the cancer diagnosis and/or loss of a loved one? (Select all that apply)(Required) Temporary or extended separation of parents or divorce Single parent diagnosed with special needs, learning disability, or illness Death of a pet Prolonged illness of another family member or close friend Moving to a new home, school, or neighborhood Parent/caregiver marriage/re-marriage History of physical/emotional abuse Change in routine, caregivers, or adult role models Breakup of friendship or relationship Failing a class or grade in school Being the victim of a crime Going into foster care or moving to a new foster care home Consistently difficult relationship with siblings, parent/caregiver, teachers Unplanned job or income loss of a parent or caregiver Arrival of a new family member (birth, adoption, new person) into the home Sexual or gender identity issues Other Financial InformationAre you receiving any of the following? SSI Benefits SNAP (MA Only) WIC CalFresh Other Are you receiving or in the process of applying for affordable housing? Yes No Not Applicable Do you have a Section 8 voucher? Yes No How did the circumstances of the cancer affect finances for the family? Please describe the family's current financial picture.(Required)If you were employed prior to your diagnosis, have you been able to continue to work at the "rate" that you did before being diagnosed? If not, please explain the difference in your ability.(Required)Please list your current employer (if you are employed) FundingRunway for Recovery provides grants up to $30,000 for families. Grants are awarded to families but Runway will pay third parties directly for any services rendered to the family and/or any fees associated with a funding bucket.What buckets of funding would be most helpful to your family?(Required) Summer camp fees & travel to/from camp Childcare services (daycare, babysitting, before & after school care) Counseling services for the caregiver/children Playgroup therapy sessions for the children Support groups for adults Tutoring/other academic support for children Extracurricular activities fees for children Alternative healing and wellness classes (acupuncture, yoga, meditation) Books, supplies for academic work Continuing education or vocational training for caregiver Continuing school tuition Gym memberships Financial Advising Housekeeping or professional organizer services Meal Support (grocery cards, meal delivery services) Gas cards, public transportation cards Are there other areas of funding not included above that would be helpful to the family?(Required) Please select your current citizenship status(Required) U.S. Citizen Permanent Resident (Green Card Holder) Non-U.S. Citizen, Currently Residing in the U.S. Non-U.S. Citizen, Currently Residing Outside the U.S. I prefer not to answer Demographic InformationAre you of Hispanic, Latino, or of Spanish origin?(Required) Yes No How would you describe yourself?(Required) American Indian or Alaska Native Asian Black or African American Hispanic or Latino Native Hawaiian or Other Pacific Islander White Other Gender(Required) SubmissionWe fully respect and uphold the privacy of each applicant. All information gathered through grant applications is kept secure and confidential. If you would like to be notified about grant deadlines and about Runway for Recovery news, grant opportunities, and events, please join our mailing list. For questions or more information, please email us at runway@runwayforrecovery.org.Emergency Contact First Name(Required)Emergency Contact Last Name(Required)Emergency Contact Address(Required)Emergency Contact Email(Required)Emergency Contact Phone Number(Required)How did you hear about Runway?(Required)Dana FarberBBCECBoston Medical CenterEmpower HERThe Children's RoomJeff's PlaceMGHNewton-Wellesley HospitalThe Healing GardenSt. Joseph's Hospital, Orange, CARunway ModelTuftsSocial Media/Website/BlogYankee HomecomingJoe Andruzzi FoundationOtherIs there anything else we should know?Acknowledgements(Required) I understand the written application is complete and I will book a 360-Evaluation on the next screen. I authorize the Runway Care Team, which is made up of social workers and a licensed RN, to share information from the 360-Evaluation with the Runway for Recovery Family Grant Committee Select All
