Cancer Assistance Application

Team Buche Cares understands a cancer diagnosis not only affects health and well-being, it brings a tremendous expense and burden to families traveling for care, missing work or juggling their everyday needs. Team Buche Cares may provide some help to defray the costs of care.

Team Buche Cares’ focus remains on communities and families in rural South Dakota. Requests for funding will be presented to the Team Buche Cares Board of Directors. Unfortunately, not all requests will be granted. Successful applicants will be contacted directly by the Team Buche Cares.

Cancer Fund Assistance Application

"*" indicates required fields

Applicaton Information

Cancer Patient Name*

First Last

Date of birth*

Phone*

Address*

Street Address Address Line 2 City State ZIP Code

Contact Person

If different from the patient.

First Last

Type of Treatment*

Date of Diagnosis*

Verification of Diagnosis*

Please upload a dated doctor's note, treatment plan, or other official document that confirms the diagnosis.

Max. file size: 256 MB.

Please tell us more about your cancer diagnosis and why you are requesting assistance.*

Type of Assistance Requested & Amount

Type of Assistance Requested & Amount*

List all expenses you are requesting assistance for including travel, lodging, medications, meals, medical supplies and other living necessities.

Expense Item

Expense amount ($)

Total Amount Requested*

Who will be picking up the gift cards?*

Individuals picking up gift cards will need a valid ID. Please include First and Last Name.

If picking up assistance at one of our stores, which location?*

How did you hear about our cancer assistance application?*

Please enter first/last name, store location or any other details.

Signature*

Date*