DOOR CANcer Inc. hopes to alleviate suffering through monetary aid for families battling the financial drain of a cancer diagnosis.

$ Million

DISTRIBUTED IN
FINANCIAL AID

People

SERVED BY OUR
ORGANIZATION

OUR VALUES
MAKE US SPECIAL

VOLUNTEER
BOARD OF
DIRECTORS

Board: All of the funds we raise go DIRECTLY to helping patients.

TRUSTWORTHY & TRANSPARENT

Trustworthy: Our proceedings and finances are available.

CONFIDENTIAL & EFFECTIVE

Confidential: We respect your privacy and protect the identity of our recipients.

Support our Cause

DONATE

Let us Support You

DOOR CANcer Inc.

APPLICATION FOR FINANCIAL ASSISTANCE

Applications must be received by the First Friday of any month. Late applications will be considered for the next month: (Sorry, No Exceptions)

"*" indicates required fields

DOOR CANcer Inc. provides Door County, WI residents in treatment for cancer with funds to assist with heating and utility payments, groceries, gasoline, insurance premiums, lodging and more. (We do not pay medical bills)

Applicant's Name*

Age*

Applicant's Address*

Alternate Contact

Person completing this form*

Home Phone

Cell Phone*

E-Mail Address*

Are you currently in ACTIVE treatment?*

If Yes

If Yes*

Chemo

Radiation

Other

Number of members in household:*

Adults*

Children (list ages)

Please specify on this form how DOOR CANcer can help you (Example: transportation, groceries, utilities, lodging, etc.) If bills you are requesting assistance with are on an automatic withdrawal plan from your checking account, we need to know this. With all requests, we need account numbers and addresses.

Consent*

I certify that the information provided here is true and complete to the best of my knowledge.*

Signature*

Electronically Signed.

Date of Signing*

NOTE: All information on this form will be kept confidential between the applicant and DOOR CANcer Board members and committees.

We can’t promise that we can help every applicant with every request, but we do promise to do our very best to help ease your financial worries during your journey through your cancer treatments.

Please list out the detail on what type of Financial Assistance you are requesting

Expense/Company/Organization Owed

Amount Requested

Account No.

Address & Telephone Number

Auto-Withdrawal (y/n)

Click the + (plus) button to add more lines as you can ask for help on more than one type of bill/expense.

Please answer this easy question to verify you are not a robot: What is 2+ seven? Enter the answer here:

CAPTCHA

Name

This field is for validation purposes and should be left unchanged.

or PDF format form.

OUR ORGANIZATION WAS FOUNDED IN 1997 BY CANCER SURVIVORS AND PATIENTS

WE’VE EXPERIENCED THE FIGHT FIRSTHAND AND HAVE DESIGNED AN ORGANIZATION TO HELP

Barb Herdina
(President)

Mary Lu Norton
(Vice President)

Terrie Haen
(Treasurer)

Kris Husby-Nelson (Correspondence)

Danny Hanson
(Secretary)

Jamie Alberts

Nell Herlache

Susie Wehrli

Jenny Brandenburg

Carly Sarkis

WE UNDERSTAND
WHAT YOU’RE
GOING THROUGH,

AND WE’RE HERE TO HELP

DOOR CANcer Inc. hopes to alleviate suffering through monetary aid for families battling the financial drain of a cancer diagnosis.

DISTRIBUTED IN
FINANCIAL AID

SERVED BY OUR
ORGANIZATION

OUR VALUES
MAKE US SPECIAL

VOLUNTEER
BOARD OF
DIRECTORS

Board: All of the funds we raise go DIRECTLY to helping patients.

TRUSTWORTHY & TRANSPARENT

Trustworthy: Our proceedings and finances are available.

CONFIDENTIAL & EFFECTIVE

Confidential: We respect your privacy and protect the identity of our recipients.

Support our Cause

Let us Support You

OUR ORGANIZATION WAS FOUNDED IN 1997 BY CANCER SURVIVORS AND PATIENTS

WE’VE EXPERIENCED THE FIGHT FIRSTHAND AND HAVE DESIGNED AN ORGANIZATION TO HELP

Barb Herdina
(President)

Mary Lu Norton
(Vice President)

Terrie Haen
(Treasurer)

Kris Husby-Nelson (Correspondence)

Danny Hanson
(Secretary)

Jamie Alberts

Nell Herlache

Susie Wehrli

Jenny Brandenburg

Carly Sarkis

Lauren Schar

Amy Stephens

Jerry Worrick

WE UNDERSTANDWHAT YOU’REGOING THROUGH,

AND WE’RE HERE TO HELP

DOOR CANcer Inc. hopes to alleviate suffering through monetary aid for families battling the financial drain of a cancer diagnosis.

DISTRIBUTED INFINANCIAL AID

SERVED BY OURORGANIZATION

OUR VALUES MAKE US SPECIAL

VOLUNTEERBOARD OFDIRECTORS

Board: All of the funds we raise go DIRECTLY to helping patients.

TRUSTWORTHY & TRANSPARENT

Trustworthy: Our proceedings and finances are available.

CONFIDENTIAL & EFFECTIVE

Confidential: We respect your privacy and protect the identity of our recipients.

Support our Cause

Let us Support You

DOOR CANcer Inc.

OUR ORGANIZATION WAS FOUNDED IN 1997 BY CANCER SURVIVORS AND PATIENTS

WE’VE EXPERIENCED THE FIGHT FIRSTHAND AND HAVE DESIGNED AN ORGANIZATION TO HELP

Barb Herdina(President)

Mary Lu Norton(Vice President)

Terrie Haen(Treasurer)

Kris Husby-Nelson (Correspondence)

Danny Hanson(Secretary)

Jamie Alberts

Nell Herlache

Susie Wehrli

Jenny Brandenburg

Carly Sarkis

Lauren Schar

Amy Stephens

Jerry Worrick

WE UNDERSTAND
WHAT YOU’RE
GOING THROUGH,

DISTRIBUTED IN
FINANCIAL AID

SERVED BY OUR
ORGANIZATION

OUR VALUES
MAKE US SPECIAL

VOLUNTEER
BOARD OF
DIRECTORS

Barb Herdina
(President)

Mary Lu Norton
(Vice President)

Terrie Haen
(Treasurer)

Danny Hanson
(Secretary)