Request an Application

If you meet the listed eligibility requirements, please fill out the form below to request an application. Requests will be honored only during our open period. We are hopeful that past recipients and their families will help spread our pursuit and pay it forward to help another.

Eligibility Requirements:

  • You are a young adult between the ages of 15-36.
  • You are personally undergoing treatment or have finished protocol (within 8 months) for a rare cancer.
  • You are a citizen of the United States.

Important Dates:

  • Applications Open: Feb 1, 2018 – Feb 21, 2018
  • Applications Open: July 1, 2018 –  July 21, 2018

Please note that due to its high prevalance, breast cancer in your twenties is considered rare.

Contact for further questions.