Application for Financial Assistance

  1. Download the Application form below.

  2. Complete all fields on the form.

  3. Fax form to: (765) 481-2262 -or- Mail to: 117 West Elm Street Lebanon, IN 46052

Boone County Cancer Society will review this information and contact the person requesting financial assistance.

All information is strictly confidential and is for Boone County Cancer Society’s use only.

Questions? See our F.A.Q. or call (765) 482-2043