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Apply for Assistance

Please use this form to contact the Daniel T. Liss Memorial Fund in regards to applying for assistance or a donation. We are a small fund, run purely off of volunteers and love, so we ask for your patience in a response.

Please fully complete the form below, with the following information, in order for your application to be considered completed.

MUST INCLUDE:
- All applicants must be children, who are a cancer patient, a child with a parent that is a cancer patient or a sibling of a cancer patient.
- Your name and relationship to applicant
- Your email address and preferably a phone number as well
- A brief medical history of the patient (date of diagnosis, current condition, where they are being treated, etc.)
- Age and interests of the child(ren)
- Location of the family you are applying for

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