Scholarship Application | Keep Climbing Foundation

Section 1

Parent / Guardian Information

Tell us how to reach you about the application.

Full name*

Relationship to child*

Phone number*

Email address*

Street address*

City*

State*

Zip code*

Preferred contact method*

PhoneEmailText

Section 2

Child Information

Basic information about your child.

Child’s full name*

Date of birth*

Current age*

Section 3

Medical Information

Help us understand the diagnosis and current care context.

Primary diagnosis*

Date of diagnosis*

Stage or severity

Optional if not applicable.

Treatment facility or hospital name*

Treatment facility city*

Treatment facility state*

Please share your child’s medical journey so far*

Section 4

Treatment & Care Details

A snapshot of treatment timing and current care.

Treatment start date*

Is your child currently in active treatment?*

YesNo

Current treatment type(s)*

Examples: chemotherapy, radiation, surgery, immunotherapy.

Expected duration or next major treatment milestone

Optional if not known.

Section 5

Insurance & Assistance

Insurance and outside-support context helps the board review applications fairly.

Do you have medical and/or prescription insurance?*

YesNo

Are you currently receiving assistance from other foundations or programs?*

YesNo

Section 6

Financial & Practical Impact

This section helps the foundation understand where support would make the greatest difference.

Has your family experienced a loss of income due to your child’s diagnosis?*

YesNo

Household size*

Approximate annual household income*

A range is fine.

What medical or treatment-related bills would this scholarship help cover?*

Have medical expenses created financial hardship for your family?*

YesNo

Section 7

Family & Household Context

Share anything else that may help the board understand your family’s current situation.

Is there anything else about your family’s situation you’d like us to know?*

Section 8

Your Story

This story helps the board understand the human side of the application.

Please share your child’s story and how this diagnosis has impacted your family*

May the Keep Climbing Foundation use your story and/or photos you provide in marketing materials?*

YesNo

Section 9

Supporting Documentation

These documents are optional and recommended. You do not need to upload them right now. Let us know what you can provide if requested.

Which documents can you provide if needed?

Recent medical bills or statements you would like us to payTreatment summaries or care plansLetter from social worker, nurse navigator, or care coordinatorInsurance explanation of benefits (EOB) or copay summaries

Anything else you want us to know about supporting documents

Optional. Note if documents are available on request or need explanation.

Section 10

Consent & Verification

All consent items are required before the application can be reviewed.

I certify that the information provided is true and accurate to the best of my knowledge.*

I understand that scholarship funds will be paid directly toward approved medical or treatment-related expenses.*

I consent to verification with treatment providers or care coordinators if required.*

I understand that scholarships are awarded based on board review, eligibility, and available funds.*

I authorize the Keep Climbing Foundation to use the information provided solely for evaluating this application and administering scholarship support.*

Security Check

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Need help instead? Email info@keepclimbingfoundation.org.

Medical scholarship application

Before you start

How support works

Parent / Guardian Information

Child Information

Medical Information

Treatment & Care Details

Insurance & Assistance

Financial & Practical Impact

Family & Household Context

Your Story

Supporting Documentation

Consent & Verification

Security Check

Ready to have an impact?