Grant Application — Race with Grace | The Mary Grace Memorial Foundation

We’re here for you.

The Mary Grace Memorial Foundation exists to provide financial relief to individuals fighting cancer so they can focus on their health. Our goal is to make the application process as easy as 1, 2, 3.

Step 1 - Determine if you qualify.

You qualify for a grant if all of the following apply to you:
a) You’re undergoing active treatments.
b) You live exclusively in Medina, Stark, or Wayne Counties.
c) You can provide medical documentation.
d) You can provide documentation of bills to be issued directly to 3rd parties only – i.e. mortgage payments, rent payments, utility bills, etc.
e) You have not yet applied this calendar year. (Individuals can only apply once/year.)
Step 2 - Fill out the application.

Applications can be submitted online or via mail.
a) To submit online, simply scroll down to the secure web form below. Please note that if you submit online, you will still need to mail supporting materials (see step 3).
b) To submit via mail, fill out this downloadable application and mail with your supporting materials (see step 3).
Step 3 - Mail supporting materials.

You must complete this step to have your application processed!
Whether you submit the application online or choose to print and mail it…
a) You will need to mail a copy of your pathology and/or medical report. (We don’t need an entire medical report, but rather something dated that verifies you have been diagnosed with cancer and are actively receiving treatment.)
b) You will also need to mail copies of the bill(s) for which you’re requesting financial assistance.
Mail verification items to:
The Mary Grace Memorial Foundation
PO BOX #1822
Medina, Ohio 44258

Download the application here (or submit online below).

Interested in submitting the application online?

Please fill out the application below and push "submit" when complete. Then, don't forget to mail your verification items! (See above.) Applications cannot be processed until medical documentation and copies of bills are received.

Personal Information

Today's Date

YYYY

Name

First Name

Last Name

Qualifying County of Applicant

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Email Address

Age

Referred by:

If patient is minor, name of parent or guardian:

First Name

Last Name

Medical Information

Physician's Name

First Name

Last Name

Facility

Physician's Phone

(###)

###

####

Nurse / Social Worker Name

First Name

Last Name

Facility

Nurse / Social Worker Email

Nurse / Social Worker Phone

(###)

###

####

Household Information

Marital Status

How many persons are living in your household?

Include yourself, all adults, and children:

Do you rent or own your home?

Do you have health insurance?

If yes, check all that apply:

Medicaid

Medicare

Disability Insurance

Other

Have you received a grant from the Mary Grace Memorial Foundation in the past?

Needs Assessment

All financial assistance payments are to be made to 3rd parties (i.e. your mortgage lender). Please indicate your top 2 payments requested, in order of priority. You may request assistance with mortgage, rent, or utilities.

Payee 1 Name

Payee 1 Account Number

Payee 1 Address (Street, City, State, Zip)

Payee 1 Phone Number

(###)

###

####

Payee 1 Amount Due

Payee 1 Due Date

YYYY

Payee 1 Comments

Is there anything else you'd like to communicate about this bill or payee?

Payee 2 Name

Payee 2 Account Number

Payee 2 Address (Street, City, State, Zip)

Payee 2 Phone Number

(###)

###

####

Payee 2 Amount Due

Payee 2 Due Date

YYYY

Payee 2 Comments

Is there anything else you'd like to communicate about this bill or payee?

More About You

Well, this is the big one... perhaps the most important part of your application for grant funds, as the following questions allow our Board the opportunity to get to know you as an individual. Please provide answers to the following:

First, please tell us briefly of your life leading up to your illness (relationships, home life, work life, etc.).

A cancer diagnosis can create significant disruption. Please tell us how your diagnosis has affected you, and how you are now in financial need.

Finally, describe your hopes for the future.

Thank you for sharing your story with us. The Mary Grace Foundation exists to provide financial relief to individuals so they can focus on their own health. When submitting this application, for verification purposes, please be sure to mail a copy of your pathology and/or medical report. (We don’t need an entire medical report, but rather something dated that verifies you have been diagnosed with cancer and are actively receiving treatment.) Please also mail copies of the bill(s) for which you’re requesting financial assistance. Applications cannot be processed until medical documentation and copies of bills are received.

Acknowledgment & Electronic Signature

I understand and agree that no promises or assurances whatsoever have been made to me by any representative of The Mary Grace Memorial Foundation regarding the assistance I am requesting. I understand and grant my permission to all my doctors, clinics, and hospitals to provide information to The Mary Grace Memorial Foundation relating to any treatment and care for cancer and other related health problems when necessary. The Foundation agrees that all medical information will remain confidential, and any reports written about the program will not use any participants' names without their express permission. I understand and agree that fulfillment of assistance may result in publicity, whether or not The Mary Grace Memorial Foundation actively takes steps to publicize its services. I understand and recognize that the granting of any service and the participation of any person in the assistance is contingent upon approval by The Mary Grace Memorial Foundation. I also understand that there is a limit to the number of services that I will receive, depending on the type and cost of service being requested and offered.

First Name

Last Name

Date

YYYY

We’re here for you.

Step 1 - Determine if you qualify.

Step 2 - Fill out the application.

Step 3 - Mail supporting materials.