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Lucy's Children Application

Our Programs

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Apply for Funding

We're so glad that you found us, and we can't wait to start working with your family and child!

Through our Lucy's Children™ program, anyone in New England who was diagnosed with cancer before the age of 21 years is eligible for funding for integrative therapies from Lucy's Love Bus. Our funds are available for those currently undergoing treatment or suffering from the late effects of cancer treatment. We will award funding as available. We invite families of children living in or receiving treatment in New England (MA, NH, VT, ME, RI, or CT) to apply today; we will be in touch to let you know the availability of funding, and we are always here for support and questions! For those families outside of New England, please visit our Resources page for organizations that may be able to help in your area.

For additional questions, please refer to our FAQs. We will always be here for support and questions through your child's cancer treatment and beyond. We will be in touch as soon as we receive your application to let you know about the availability of our funding.

Below, you have the option to complete the application in its entirety online, right on this page, or you can download the forms below. 

Lucy's Children™ Application for Funding

Below you will find the online version of our application. All information is encrypted, private, and secure. 

Please note: this application includes personal information and the signature of the child's parent/guardian in order to release that information. If you are not the parent/guardian but would like to help the family of a child with cancer to complete the application and they are not present with you for the signature portion required below, please complete a referral form, or download the application (above) to share with the family.

Lucy's Children™ Application Intake Form
Child's First Name
Or your information if you are over 18 applying for yourself.
Child's Last Name
Or your information if you are over 18 applying for yourself.
Month
/
Day
/
Year
Or your information if you are over 18 applying for yourself.
Child's pronouns
Or your information if you are over 18 applying for yourself.
Individual funding through Lucy's Children™ is available only for those who were diagnosed with cancer before the age of 21.
Month
/
Day
/
Year
Please select all that apply
This helps us with grant information and so that we can share additional resources with you!
Which best describes your child's treatment status?
Child's Address
State
We are only able to provide funding to children living in/being treated in New England at this time.
Parent/Guardian Name
If you are a patient over the age of 18, please write SELF
(We prefer email whenever possible, to help track communication easily.)
Se habla español.
Text o email está preferido para comunicación en español.
If the parent/guardian does not speak English and we should use another person as the primary contact, please provide their information below:
In which hospital is your child treated?
Please enter your child's oncologist and his/her phone or email.
Please enter your child's social worker and his/her phone or email.
Top integrative therapies
What are your child's top choices for integrative therapies? (Select up to 3.)
Note: We require a signed medical permission form from your child's oncologist clearing their participation in any activities of interest. See more at the end of the application below.
Do you already know who you would like for your child to work with/where you would like them to go for their chosen therapy?
If your child is currently working with an integrative therapist, please give us their information here:
If your child is already working with someone, please call them and a) let them know someone from LLB will be calling to discuss payment and ask who the best person to speak to about billing would be, and b) give them permission to speak to us about your child.
What physical and emotional symptoms are you hoping to help your child alleviate through the use of integrative therapies?
Do you need a practitioner who can visit your child at home? (For massage, acupressure, aromatherapy, art/music therapy, meditation, or yoga.)
Depending on your location, we try to find practitioners within 25 miles for most services, 50 miles for therapeutic horseback riding.

Medical Permission For Therapies

We require a medical permission form signed by your child's oncologist clearing his/her participation in any/all therapies your child may want. We must receive this signed permission form before we can pay for services for your child. Please click below to download the form (which may be submitted at a later time) and upload the signed form below if you may have that piece completed already.

We will need a medical permission form signed by your child's oncologist in order for him/her to receive integrative therapies, paid for by Lucy's Love Bus. Do you already have this form signed?
Please be sure to double check both your email address and your social worker's email address if you need us to email the medical permission form!
If the permission form is already signed by your child's oncologist, you can upload the file here.
No file selected
Please note: if you do not have the signed permission form at this time, it can be submitted separately by email, fax, or mail. We will need it completed before your child can receive services.

Demographic information

This optional information is collected to measure our impact to report on grants and with funders to ensure that we can continue to receive funding for this program. All information is confidential.

Child's ethnicity
Or your information if you are over 18 applying for yourself.
Please check the corresponding box(es) below if the child for whom you are applying identifies as/with:
Please check thPlease check the corresponding box(es) below if the child for whom you are applying identifies as/with:e corresponding box(es) below if you (the parent/guardian) identify as/with:
Please check the corresponding box(es) below if you (the parent/guardian) identify as/with:
Please check the corresponding box(es) below if you (the parent/guardian) identify as/with:

We pride ourselves on matching your child with the best practitioner(s) to meet their needs. While we require proof of applicable certifications and licenses from the practitioners we work with, we require that you stay with your child throughout their appointment to ensure their safety and comfort.

Lucy’s Love Bus has provided this material for your information. It is not intended to substitute for the medical expertise and advice of your primary health care provider. The mention of any product, service or therapy is not an endorsement by Lucy’s Love Bus.

The Grant Process: What happens now?

Once we receive the completed application for your child, we will confirm receipt and discuss current options for funding. Please allow up to two weeks for initial contact after you submit your application. 
*Please allow up to two weeks between submitting your application and our ability to pay for your child’s services; we cannot guarantee that we will be able to pay for an appointment or a fee that is due within two weeks of receiving this application due to paperwork needed from the provider.*

Once funding becomes available for your child, we will reach out 3 times by your preferred contact method to arrange for connecting your child to therapies. If we are unable to reach you, we will reallocate the funding to another child with an immediate need, and you are welcome to reach out when your child is ready to receive services for an update on our availability of funding.

By accepting funding from Lucy’s Love Bus, you agree to participate in one brief annual survey so that we can assess our programs and to aid in securing more funding for children with cancer. This survey is conducted by email or phone, consists of 5 questions, and takes less than 5 minutes to complete. We appreciate your support in capturing the benefits of our work together. Your signature below signifies that you agree to participate in this survey, and that all information submitted as part of this application and in the future to Lucy's Love Bus is true. All electronic signatures below must be completed by the child's parent/guardian.

Electronic signature
By checking this box and signing my name below, I am electronically signing this agreement.
Electronic signature
Month
/
Day
/
Year

 

Through our Sajni’s Siblings program, we pay for siblings to participate in integrative therapies together, or pay for them to have a separate integrative therapies (restrictions apply).
No file selected

Thank you for completing the intake portion of the application! Please review our HIPAA Notice of Privacy Policies, Authorization to Use or Disclose Health Information, and Release and Agreement and sign each below in order to complete the application in full.

 

HIPAA Notice of Privacy Policies

PRIVACY POLICIES ACKNOWLEDGEMENT

I have received, read and understood the Notice of Privacy Policies of our organization.  I understand how Lucy’s Love Bus Charitable Trust may use or disclose my child’s health information.  I understand when Lucy’s Love Bus Charitable Trust may not use or disclose my health information. I understand my child’s health information rights and understand that Lucy’s Love Bus Charitable Trust reserves the right to change this Notice of Privacy Practices.  I also understand how to place a complaint regarding this Notice and have also been provided the opportunity to review and question the privacy policies of Lucy’s Love Bus Charitable Trust.

Electronic signature
By checking this box and signing my name below, I am electronically signing this agreement (HIPAA Notice of Privacy Policies).
Electronic signature
Month
/
Day
/
Year

 

Authorization to Use or Disclose My Health Information

This disclosure agreement allows us to give general health information to local practitioners in order to connect your child to the best practitioner given his/her individual health situation and needs. The most we will share as a part of the search process is: age, diagnosis, and symptoms. 

I. My Authorization
You may use or disclose the following health care information (check all that apply):
I. My Authorization (continued)
You may disclose this health information to:
II. My Rights
I may revoke this authorization in writing. If I did, it would not affect any actions already taken by Lucy's Love Bus based upon this authorization. To revoke this authorization, write a letter to our Director at: Lucy’s Love Bus, PO Box 464, Amesbury, MA 01913. Once the office discloses health information, the person or organization that receives it may re-disclose it. Privacy laws may no longer protect it.
Electronic signature
By checking this box and signing my name below, I am electronically signing this agreement (Authorization to Use or Disclose Health Information).
Patient or legally authorized individual signature
Month
/
Day
/
Year
Signee's relationship to patient

 

Release and Agreement

Electronic signature
By checking this box and signing my name below, I am electronically signing this agreement (Lucy's Love Bus Release and Agreement).
Electronic signature
Month
/
Day
/
Year

If you're ready, click "Submit Now" and your application will be sent to Kerry, Children's Programs Manager! If your application is submitted successfully, you will be redirected to a confirmation page and sent a confirmation email to the email address you listed above. 

If you do not see a confirmation page and receive a confirmation email, your form was not submitted successfully; please refresh, or complete a downloadable application below and submit to Kerry@LucysLoveBus.org.

Please allow 1 week for a response by your preferred method of communication after you click "submit now." For questions, please email Kerry@LucysLoveBus.org or call 781-454-8535. Welcome aboard the Love Bus! 

*Remember: if you clicked the "Submit Now" button above and your page did not redirect to a confirmation page or you did not receive a confirmation email, your application has not been submitted. Please click the above button again; if it still does not work, please go to File > Print and change destination to "Save as PDF." This will allow you to save all of the entered information as a PDF; please email this PDF to Kerry@LucysLoveBus.org (the formatting will look weird, but all of the information you entered should be saved).

 

Below you will find downloadable versions of our full application. Once completed, please submit in one of the following ways:

Email to: Kerry@LucysLoveBus.org
Fax to: (978) 517-1567


Mail to:
Lucy's Love Bus (Attn: Jackie)
PO Box 464
Amesbury, MA 01913

We will be in touch once we receive your application to welcome you aboard the Love Bus!

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