To request enrollment into our program, please complete the following forms. You may email the forms to us by clicking below, or fax or mail to us at:
Jason's Friends Foundation
340 West B Street, Suite 101
Casper, WY 82601
Office: (307) 235-3421
Fax: (307) 265-4668
Qualifying Requirements for our Program
- Child must be under the age of 21 years old
- Child's diagnosis must be a brain tumor, spinal cord tumor or childhood cancer
- Parent/guardian must be a Wyoming resident
Family Enrollment Request Form
Agreement Form
HIPAA Release of Information Form
Please note: Direct referrals, that do not come from the hospital social worker, require a written diagnosis from the hospital/doctor. A copy of your driver's license is also required.
To submit emails and enrollment forms, click here.
Additional Forms for Enrolled Families
Household Bills Payment Request Form