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Are you requesting assistance for yourself or someone else?
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Provide the name of individual the assistance is for:
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What is the recipient's current diagnosis?
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Type of Cancer
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Type of Treatment prescribed:
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**Please Select**
Surgery
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Immunotherapy
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If "Other" Treatment prescribed, please explain:
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How did you hear about The Nicole Wicox Foundation?
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If "Other" selected, please explain:
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Request a Treatment Bag?
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Our Treatment Bag includes the basic necessities needed during treatment.
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Please Note:
The Foundation does not give cash or checks directly to anyone in need. We will take the information for the bill/payment in need and work directly as able.
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