Life List Program Application


Dear Jack Foundation Life List Program Application

Thank you for your interest in the Life List program. Our Life List wish granting program works closely with adolescent and young adult patients who have received life-threatening cancer diagnoses by giving them positive activities and adventures to focus on during treatment. The program also provides the opportunity to connect with a community of AYA patients and survivors who have experienced similar journeys.

Do I qualify? LifeList program prerequisites:
You may be eligible for the LifeList program if you are a cancer patient between the ages of 18-39, referred by a medical care team member, and meet one of the following criteria:

  • A patient that goes above and beyond the patient treatment norm.
  • Recently experienced a relapse of a primary cancer or a secondary cancer diagnosis.
  • Enrolled in clinical trial where standard treatment protocols have proven unsuccessful.
  • You are experiencing difficult extenuating circumstances.

  • LifeList Program Guidelines:
  • Your LifeList items can total up to $2000 and include anywhere from 1-4 wishes.
  • $200 of your total can be allocated toward a wish for your caregiver.
  • We are happy to fulfill wishes for items via invoices or a direct purchase of request. We are unable to accept wish requests for ‘generic’ VISA/AMEX, Amazon gift cards, cash, or financial assistance (rent, mortgage, home repairs, car payments, student loan payments, medical expense reimbursement, credit card payments, etc).
  • You are an active part of the program for a total of 6 months from the date of acceptance. All LifeList items requested must be completed or ordered within 6 months of acceptance. Any trips requested should fall within that time frame. Please be aware of your health status and the reality of being able to fulfill your requests within 6 months.