McHenry Area CHARACTER COUNTS! Coalition
Helping Local Children Fighting Cancer
Family Application Form: Due March 1
To Submit: Save Form and Email to ​[email protected]
or mail to Cindy Witt
City of McHenry
333 South Green Street
McHenry, IL 60050
Purpose
The purpose of this program is to work with local school districts to raise money and allocate funds to assist local children and their families
within the District 156, 15 and 36 boundaries who are fighting cancer and are incurring financial hardship due to extra expenses related to
fighting this battle. Also eligible are the children of CC! Coalition members. Please supply the following information and return to the McHenry
Area CHARACTER COUNTS! Coalition.
Child Information​ (must be of high school age or younger)
Child Name: Birth Date: School: Parent Names: Family Address: City: Zip: Primary Contact/Phone Number: Information about Sickness and Financial Hardship
Type of Cancer (Disease Name): Date of Diagnosis: Contact Phone: Is the Cancer in Remission? Yes☐ No☐
Please describe the current state of illness/treatment: Approximate out of pocket costs per month related to illness (medicine/treatment/doctor visits): Please provide information on the current state of financial hardship for the family. This can include other
costs including travel and/or hotel/lodging related to fighting the illness or other needs of the family that
are lacking due to financial costs of the illness. Someone from the Character Counts! Coalition will make a personal contact with you soon!