Home
Apply here
About Us
Our Mission
Boards
Fundraising Tips
Contact Us
Log In
One-to-One Fund Application
All fields required.
Patient's First Name
(*)
Please enter the patient's first name
Patient's Last Name
(*)
Please enter the patient's last name
Patient's E-mail
(*)
Please enter a valid email
Confirm E-mail
(*)
Please repeat the patient's email
Password
(*)
Please enter a password!
Confirm Password
(*)
Passwords don't match. Please try again
Patient Information
Date of Birth
(*)
Month
01
02
03
04
05
06
07
08
09
10
11
12
/
Day
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
/
Year
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Please enter the patient's birth date
Age
(*)
Invalid Input
Sex
(*)
Please select *
Male
Female
Please select a gender
Address
(*)
Please enter a valid address
City
(*)
Please enter a city
State
(*)
Please enter a State
ZIP
(*)
Please enter a valid ZIP
Phone
(*)
Please enter a valid phone number
Preferred Language
(*)
Please select
English
Spanish
Other
Please select a preferred language
Race / Ethnicity
(*)
Please select *
Hispanic / Latino
Native American
Asian
African American / Black
White / Non-Hispanic
Other
Please select
Responsible Family Member
(*)
Please insert a responsible family member
Fundraising Coordinator
Fundraiser Coordinator
(*)
Please insert a fundraiser coordinator
Relationship to Patient
(*)
Please tell us the Fundraiser Coordinator relationship to Patient
Phone
(*)
Please enter a valid phone number
E-mail
(*)
Please enter a valid email
Financial Information
Check Payable To
(*)
Please tell us to whom should we address the check
Send Check To (name)
(*)
Please tell us to whom we should send the check
Address
(*)
Please enter a valid address
City
(*)
Please enter a city
State
(*)
Please enter a State
ZIP
(*)
Please enter a valid ZIP
I would like information about the programs selected below
Lifeline Fund - Patient financial assistance grant program
Ask the Expert - Advice from transplant professionals
SupportLine - Patient-to-Patient peer support
Telephone Support Group
Invalid Input
Hospital and Treatment Information
Complete Diagnosis
(*)
Enter the diagnosis
Date / Expected date of BMT
(*)
Select date or expected date of BMT
Transplant Hospital
(*)
Please insert a hospital
Address
(*)
Please enter a valid address
City
(*)
Please enter a city
State
(*)
Please enter a State
ZIP
(*)
Please enter a valid ZIP
Physician
(*)
Please enter the name of the physician
Physician Email
(*)
Please enter a valid email
Physician Phone
(*)
Please enter a valid phone number
Nurse Coordinator
(*)
Please insert a nurse coordinator
Nurse Coordinator Email
(*)
Please enter a valid email
Nurse Coordinator Phone
(*)
Please enter a valid phone number
Social Worker / Nurse
(*)
Please tell us the nurse or social worker name
Social Worker / Nurse Email
(*)
Please enter a valid email
Social Worker / Nurse Phone
(*)
Please enter a valid phone number
Type of Transplant (check all that apply)
(*)
Autologous
Allogeneic, related
Allogeneic, unrelated
Bone marrow
Stem cell
Cord blood
Please select at least one type of transplant
Patient Story
Describe current treatment, living and financial situation.
(*)
Please fill this field
(*)
I certify I have read the attached document and understand the One-to-One Fund Guidelines and I agree to abide by these guidelines. Please print these guidelines for your records.
View Details
You must accept the One-to-One Fund Guidelines in order to use this service.
Invalid Input
Name
(*)
Please enter the name!
Home
Apply here
About Us
Our Mission
Boards
Fundraising Tips
Contact Us
Log In