top of page
White Hydrangeas

APPLICATION FOR FINANCIAL ASSISTANCE

When individuals are diagnosed with serious medical conditions like cancer, their financial stability can be severely impacted.  The costs of medical treatments, medications, and frequent doctor visits can add up quickly, leading to significant out-of-pocket expenses.  Additionally, some individuals may be unable to work or suffer a reduction in income while relying on disability insurance.  The combination of increased expenses and reduction of income can prove extremely challenging, and add undue stress to people who are already concerned about their own health or the health of a loved one.

 

No one should have to worry about paying the bills while they are fighting for their lives. ​Long Valley Hopes can provide assistance in covering essential living expenses when there is a reduction in income due to work interruptions directly caused by an illness.

​

PLEASE READ REQUIREMENTS BEFORE COMPLETING APPLICATION

  • New Jersey Residents ONLY

  • ​

  • Download and complete Signature Page before completing application​

  • Upload Signature Page required at bottom of this page

​

​Please allow 7-10 business days for review of request

APPLICATION FOR FINANCIAL ASSISTANCE

Please take a moment to fill out the form for consideration

Your submission was successful

Upload
Upload completed Signature Page HERE:
bottom of page