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APPLICATION TO RECEIVE FINANCIAL SUPPORT FROM C.A.S.T.

Our goal is to work through doctor and oncologist offices, giving application to distribute to those most in need. If you are interested in applying for financial support from C.A.S.T., please fill out the application to the right.

After receiving completed application, we will use fundraisers and events to provide support in the form of:

Prescription drug coverage
Gas cards
Utilities (gas, electric, water, etc.)
Payments for cancer-related medical bills
Insurance deductibles

We also welcome personal referrals of patients and physicians. We will contact the necessary personnel for qualifications.

Please fill out this application as accurately as possible. If information is not accurate, eligibility will be denied.

*You will be required to submit a pay stub for your income and spouse's income, so please provide this information as accurately as possible.

Please note that every 6 months, applications must be re-submitted and approved by the C.A.S.T. Board in order to continue receiving financial support.

If you would prefer to fill this form out on paper, please download the application below and send completed for to:

C.A.S.T.
2719 Blackfriars NW
Canton, OH 44708

Questions? Click here to contact C.A.S.T.

C.A.S.T. application

* Indicates required field

Name *

First

Last

Marital Status *

Married Single Divorced

Address *

Line 1

Line 2

City

State

Zip Code

Country

Home Phone *

Cell Phone *

Oncologist's Name *

Oncologist's Phone *

Oncologist's Address *

Line 1

Line 2

City

State

Zip Code

Country

Local Pharmacy Used: *

Primary Insurance Provider *

Secondary Insurance Provider *

Income *

Spouse's Income *

Number of immediate family members living in household: *

Who referred you to C.A.S.T.? If not referred, how did you hear about us? *

Submit

CURRENTLY, THERE IS A FREEZE ON NEW APPLICATIONS. THANK YOU FOR YOUR UNDERSTANDING

APPLICATION TO RECEIVE FINANCIAL SUPPORT FROM C.A.S.T.

C.A.S.T. application