At Help The Fight, our mission is to provide support and relief to those facing the challenges of breast cancer. If you are in need of financial assistance, we encourage you to apply for funding by completing the form below.

To be considered, please submit the following:
✅ The completed funding application form.
✅ A signed Authorization for Disclosure form (download and print below).
✅ A letter from your oncologist or family doctor confirming your current breast cancer treatment.
✅ A copy of the statement for which you are requesting assistance.

All required documents must be received before we can proceed with any form of payment.

Please mail your completed forms to:
Help The Fight
143 Oakridge Drive
Mountville, PA 17554

If you have any questions or need assistance with the application process, please don’t hesitate to reach out. You are not alone—Help The Fight is here for you. 💕

Funding Form Request

Date

MM

DD

YYYY

Purpose of Request

Rationale

Approximate Cost

$

Patient's Name

First Name

Last Name

Date of Birth

MM

DD

YYYY

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

County of Residence

Phone Number

(###)

###

####

Household Income

$

Number of People In Household

e Signature

e Signature is required to finalize application

First Name

Last Name

How did you hear about us? (optional)

Email Address (optional)

Message (optional)

Please click on the Authorization For Disclosure form below to download and print: