Hand in Hand through Hardship

APPLY FOR HELP

Do you know someone or a family in need of help as they battle cancer? Please follow the steps below to see how The Adam Michael Rosen Foundation may be able to help. We will try to help as many possible because it’s our mission to do so. Together we’re Adam Strong.

  1. Fill out the grant application
    • * Proof of diagnosis is required. This MUST be mailed (certified) or faxed directly from the primary physician of the recipient.
    • PLEASE DO NOT MAIL YOUR PERSONAL MEDICAL RECORDS. We only need a letter from your physician stating that you are under his/her care and for what type of cancer.
  2. Provide specifics about your needs
    • The Adam Michael Rosen Foundation may be able to help in many ways. Whether it be financial assistance in helping pay monthly bills or mortgage, or in other ways, the more information we have the better we can assist you. Please carefully follow the instructions on the form so that we have all the information necessary to help you.
  3. Mail/Email Your Completed Application
    • Mail your completed application to:
  4. All applications are reviewed by The Adam Michael Rosen Foundation board for consideration.
    • The Adam Michael Rosen Foundation is a 501(c)3 foundation new to Orlando, Florida. It was created to honor the legacy and life of Adam Michael Rosen by fighting cancer as strong as Adam did by helping others in their fight. This new organization is still growing, yet we aim to help as many people and families possible.
    • The Foundation, a private foundation, will make grants to Section 501(c)(3) public charities and/or governmental agencies (for public purposes), for the Foundation’s charitable, religious, scientific, literary and educational purposes.  The Foundation may make grants to other types of organizations in furtherance of the Foundation’s charitable, religious, scientific, literary and educational purposes.  A particular focus for the Foundation will be to make grants to fund scientific cancer research conducted in the public interest and dog rescue programs.

  • Personal Information

  • Date Format: MM slash DD slash YYYY

  • Employment Information


  • Additional Information

  • Please provide Proof of Diagnosis (via certified mail, faxed, or emailed directly from the primary physician). PLEASE DO NOT EMAIL YOUR PERSONAL MEDICAL RECORDS. We only need a letter from your physician stating that you are under their care and for what type of cancer.
  • Please provide two personal references (non-relative)
  • The Adam Michael Rosen Foundation respects your right to privacy. The information you provided on this application will remain confidential and will not be shared with anyone outside of the grant committee.

    By your signature you attest to the accuracy and truthfulness of the information you provided, falsifying application will result in repayment of grant. Also, you understand that completion of this application does not guarantee grant approval.

  • REMINDER

    If requesting monetary assistance please send us copies of your bills along with this application. The more information we have the faster we can assist you during this tough time.

    * The Adam Michael Rosen Foundation does not grant monetary funds directly to the individual/family. If approved, The Adam Michael Rosen Foundation pays bills directly to the collector. This includes co-pays, rent, mortgage, power bills, phone bills, etc.

    Please send us copies of your bills along with this application.

  • Drop files here or

  • Hold Harmless Agreement

    I acknowledge that by completing and submitting an application for a grant, I understand that there is no guarantee of my grant being accepted and any monies dispersed. I also understand that any monies dispersed are to be used at my discretion and The Adam Michael Rosen Foundation is not to be held liable for my decisions in dispersing said monies.

    I hereby RELEASE, WAIVE, DISCHARGE, AND COVENANT NOT TO SUE, AND AGREE TO HOLD HARMLESS for any and all purposes The Adam Michael Rosen Foundation, its Board of Directors and their officers, servants, agents or volunteers FROM ANY AND ALL LIABILITIES, CLAIMS and DEMANDS.

    I further agree to indemnify and hold harmless The Adam Michael Rosen Foundation for any loss, liability, damage or costs, including court costs and attorney’s fees that occur as a result of my grant application being denied OR accepted.

    It is my express intent that this agreement to Hold Harmless shall bind the members of my family and partner/spouse, if I am alive, and my heirs, assigns and personal representatives, if I am deceased, and shall be governed by the laws of the State of Florida.

    In signing this agreement to Hold Harmless, I acknowledge and represent that I have read this agreement, understand it and sign it voluntarily as my own free act and deed; no oral representations, statements, or inducements apart from this agreement that has been reduced to writing have been made. I execute this document for full, adequate and complete consideration fully intending to be bound by the same, now and in the future.

  • Date Format: MM slash DD slash YYYY

  • Authorization to Release Medical Records

    All applicants must read and sign this form prior to their application being presented to The Adam Michael Rosen Foundation board for consideration.

    DO NOT SEND THIS FORM TO A PHYSICIAN — PLEASE COMPLETE AND SIGN YOURSELF.

    *Only one form is required per applicant, even if you were treated by multiple physicians.

  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY

APPLY FOR HELP
APPLY FOR HELP

Our mission is to help fight cancer by supporting families and patients afflicted by this disease. If you are in need of financial help as you or a loved one battles this disease, please reach out to us. We will do our best to help however we can.

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STORIES OF STRENGTH
STORIES OF STRENGTH

Is there a person in your life fighting cancer that you feel deserves the spotlight? Is there a cancer-related moment that touched your life? Let’s share our stories of strength and about these fighters to give others hope and inspiration.

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REMISSION ALLIANCE AGAINST BRAIN TUMORS
REMISSION ALLIANCE AGAINST BRAIN TUMORS

With the help of a cornerstone donation from Harris Rosen, the Remission Alliance Against Brain Tumors is reshaping cancer research by creating an open network of shared labs and studies so that groundbreaking treatments are delivered to patients faster. The hub of this new initiative runs out of University of Florida in Gainesville.

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EVENTS
EVENTS

We’re always planning fun and meaningful activities that promote our mission. We would be honored if you would join us at any or all events. Check this page often to see what’s on the calendar. We hope to see you soon at an upcoming event.

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