Cancer Survivors' Fund

Prosthetic Limb Assistance Application



First Name


                   Last Name                             DOB

Permanent Street Address Line 1 Permanent Street Address Line 2
City State Zip


Phone e-mail




Describe yourself in one paragraph


Describe your family situation in one paragraph




Yes. I am willing to do volunteer work, share my experience with young patients with cancer or other medical challenges and provide them emotional support and guidance.


Have you previously performed volunteer work? If you did, please give details.





    Yes. I have been diagnosed with cancer.

Name of your Attending Physician

Name and Location of Hospital

Description of Need



Please mail the following documentation to:

Cancer Survivors' Fund

P.O. Box 792, Missouri City, TX 77459


A letter from your attending physician verifying your medical history, current medical situation and description of the need for the prosthesis or artificial limb.


A release from you, and your parents if you are a minor, that you agree to have your name and photo published in the news media as a recipient of Cancer Survivors' Fund medical assistance and that you agree to have your name, photo and your success story to be published on this website.

Download Release

Please DO NOT print and mail this application or the essay. Use the Submit Application button below.




Submit an essay with this application. Discuss the following question. HOW HAS MY EXPERIENCE WITH CANCER IMPACTED MY LIFE VALUES AND CAREER GOALS? Essays must be a minimum of 500 words and a maximum of 1200 words. Essays may be entered in the box below or submitted separately, attached to an e-mail. Please DO NOT mail.


Last Name  

| Make A Donation |

| Home | Legal | Privacy | Site Map | Contact |

Copyright  2000-2013 Cancer Survivors' Fund