Apply for Assistance

If your child is fighting a life-threatening illness we would love to see if we can help in some way! Please complete the application below and we will be in touch to see the best way the Mighty Maddy Foundation can ease some of your burden. Please complete the application in its entirety and review the eligibility requirements.

Parent's Name

First Name

Last Name

Phone

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Child's Name

First Name

Last Name

Child's Birthdate

YYYY

Child's Diagnosis

Diagnosis Date

YYYY

Stage of Treatment

Active Treatment

Relapse Treatment

Does your child have a support social media or Caring Bridge page?

Treatment Facility Name

Treatment Facility Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Doctor Providing Treatment

First Name

Last Name

Doctor's Contact Number

(###)

###

####

Social Worker's Name

First Name

Last Name

Social Worker's Phone

(###)

###

####

Social Worker's Email

How can we help?

What would make the biggest impact for your family?

Eligibility Requirements

By checking this box, you are agreeing to the eligibility requirements outlined below in order to be considered for assistance through the Mighty Maddy Foundation. Eligibility requirements are as follows: child must be 18 years or younger, must reside in the state of Iowa, primary treatment facility must be located in the state of Iowa, child must be actively undergoing treatment for a new diagnosis or relapse for pediatric cancer or other life threatening illness, release of information form must be received to verify treatment/diagnosis. Medical release form will be provided to family after application is received.

Agree