Apply for Assistance

To apply for assistance you must currently be a resident of Rock County, WI and be in treatment for cancer. Current grant amount is up to $1,125 a year; this compensation amount is subject to funds available. These grants can be used for rent/mortgage, utility payments (water, electric, and sewer), phone/cable/internet bills, car insurance, health insurance, or car payments.

The application consists of 3 parts: an application form, authorization for disclosure of health information, and diagnosis verification form. Below are all of these forms; be sure to fully complete all of these forms before submitting application.

Rock County Cancer Coalition Application Form
Download Form
Authorization for Disclosure of Health Information
Download Form
Diagnosis Verification Form
Download Form

When you have completed all of these forms please mail them to our PO box at:
Rock County Cancer Coalition
P.O. Box 2092
Janesville, WI 53547
If you have any questions or concerns you can contact us by email at or phone at 608-754-2286

Please Note:

Due to ongoing problems with Charter and Spectrum. RCCC will no longer be able to pay those bills for our clients. There have been numerous times that they have not credited RCCC client accounts for the money, but the checks have been cashed That has led to quite a bit of trouble for the client and RCCC’s.

As applications are submitted, each will be given a case number, allowing as much confidentiality as possible, with only one board member knowing the applicant’s name. We are dedicated to being fair to everyone and it is our hope to be able to meet the needs of everyone that apply.