Apply For Assistance

It is a humbling experience asking for help. No one likes to admit that for once, you cannot stand on your own two feet and help yourself. Cancer is a debilitating disease that knows no boundaries of income or ability.

We understand the need and want to make our application as simple as possible. All applications are treated with confidentiality and compassion.

If you are a resident of Rockingham County, NC and have been diagnosed with cancer, please fill out the short form below. You can either email the form or mail in a hard copy. Whatever is most convenient for you. Our volunteer board of directors reviews each form anonymously, and someone from The Fund will get back with you with a response within a few short days.

Please provide as much detail as possible when completing the application form. While we typically help patients with utility, grocery, or pharmacy bills, we are happy to consider unique requests for financial assistance. All reasonable requests will be considered.

Please click here to download the application form or simply fill out the form below.

Employment Info

Please provide most recent pay stub, W-2, and/or income tax return (blocking your Social Security number)

Insurance Information

Monthly Household Income

Please provide the name of the financial institution and copies of the last two statements. Be sure and block your account number.

Monthly Expenses

Please give a description of your financial needs and monthly expenses and reasons for seeking assistance from the Barry L. Joyce Local Cancer Support Fund. Some, but not all may be listed below.

Additional Information

Please give a brief description of your illness (i.e. type of cancer, when diagnosed, treatments undergone, etc.).

Please list other sources of financial assistance you have received during the course of your illness.