Application

 

 

Ride 2 Survive-Sullivan County, Inc. is a community based volunteer organization whose mission is to assist with transportation expenses for Sullivan County residents or those receiving treatment locally, who are under the care of an oncologist and who have been diagnosed with cancer or pre-malignant conditions.

Transportation expenses will be supplemented to patients receiving cancer treatment at an accredited institution. Every applicant will be considered when an application is received.

HOW TO APPLY

To receive assistance with  travel-to-treatment expenses, please

–complete the online form below

OR

— click here to download a printable  application

OR

–obtain a paper application at:

  **Catskill Regional Medical Center

**Crystal Run Healthcare

**Goshen Radiation Oncology

**Radiation and Oncology Center, Middletown, NY

**Some Sullivan County Medical Practices

**Or from any  Ride 2 Survive Sullivan County, Inc. Board Member

Patient Information

Please provide the requested information.

Oncologist Information

Expenses

If you checked any of the boxes above, please provide us with a little bit more detail. For example: How many weeks of radiation will you be receiving? How many chemotherapy treatments are you scheduled to have? What is the frequency of your visits? What transportation related expenses do you anticipate, such as - parking fees, tolls, etc.
By checking the box next to "I agree" below, you are stating that all of the information you have provided is correct and accurate to the best of your knowledge. You are also authorizing a Ride 2 Survive - Sullivan County, Inc. Board Member to reach out to your oncologist to verify the information you have provided. You also understand that the personal information you provided is not necessary but is important for releasing funds. You also acknowledge the the information provided to Ride 2 Survive - Sullivan County, Inc. will remain confidential and will not be shared with any third party. We respect your privacy and any conversations with be limited to you, your oncologist and a board member of Ride 2 Survive - Sullivan County, Inc.