CLOSE TO CARE. FAR FROM STRESS. ALWAYS FREE

Support Request Application Form

We understand how important it is to stay close to care during treatment. This application helps us
learn about your situation so we can provide support as quickly and fairly as possible.
All information is kept confidential.

PATIENT & TREATMENT INFORMATION:
Patient’s Full Name
Patient’s Street Address:
City & State:
Patient’s Phone
Treatment Facility/Hospital:
City & State of Facility/Hospital
Currently Receiving Treatment:


Patient’s Email:
Type of Diagnosis (optional)
Treatment Dates:
PATIENT ADVOCATE INFORMATION:
Advocate Role



Advocate Full Name (If different from Patient’s Name)
Street Address (If different from Patient’s Address):
City & State (If different from Patient’s):
Advocate’s Phone (If different from Patient’s Phone):
Advocate’s Email (If different from Patient’s Email):
REQUESTED INFORMATION FOR YOUR STAY:
Number of People Staying:
Do you currently have access to an RV?:


Type of Support Needed:



Requested Length of Stay:




Please add any questions you might have here:
The form has been submitted successfully! You will be contacted within 48 hours.
There have been some errors while submitting the form. Please verify all form fields again.
close to care. far from stress. always free

2025 Campers for Cancer ~ 501(c)(3) pending ~ RV Relief for the Road to Recovery
(coming soon) ~ Facebook ~ Instagram ~ TikTok ~

Scroll to Top