Adults

Welcome to the CareBOX Program
Wish List Builder!
The CareBOX Program provides cancer patients in Central Texas with essential care supplies needed to thrive throughout treatment.
Step 1: Use this Wish List Builder to select the care supplies you need. Don't be shy! We encourage you to select all the items you need over the next few months. Every 3 months you are eligible to complete the Wish List again for items you need. If you previously received a durable medical item (generally mobility) we ask that you not request these items more than once.
Step 2: We require that your healthcare provider confirm your cancer diagnosis to complete your application to the program. This requires a signature from you & a signature from a representative at your treating facility. This Verification form will be good for one year.
Step 3: The CareBOX Program Team will get busy collecting the supplies you've requested! You can expect a call from a CareBOX Volunteer in 1-2wks to schedule delivery of your supplies directly to your door!
Patient Info
First Name (required)*
Last Name (required)*
Patient Phone Number (required)*
Patient Email (required)*
Street Address (required)*
Street Address 2 (if needed)
City (required)*
State*
Zip (required)*
County (required)*
Caregiver First Name (if applicable)
This is a spot to list another contact in case we cannot get ahold of you (ex. spouse, parent, child, sibling, family member, friend, neighbor, etc.)
Caregiver Last Name (if applicable)
Caregiver Phone Number (if applicable)
Caregiver Email (if applicable)
Filling out the application, my relationship to the patient is (required):*
Preferred Communication Method (required)*
Gender (required)*
Patient Birthday (required)*
MM slash DD slash YYYY
CareBOX delivery preference (required):*
How did you hear about us? (required)*
If "Other", How did you hear about us? (if applicable)
Household Info
This information is used by us for grant reporting purposes ONLY.
Total Number of People in Household above 18 (required)*
Total Number of People in Household aged 2 to 8 (required)*
Total Number of People in Household under 2 (required)*
Estimated Total Annual Household Income (required)*
Are you (Patient) a Veteran of the US Armed Forces? (required)*
Profile Info
Please share a photo of the patient to be profiled on our website (optional)
Please share a photo of the patient to be profiled on our website (optional)
Max. file size: 50 MB.
Tell us a little bit more about yourself (the patient)! Include details about family, friends, favorite activities, etc. This may be shown on our website. (optional)
Tell us a little bit more about yourself (the patient)! Include details about family, friends, favorite activities, etc. This may be shown on our website. (optional)
Occasionally we have opportunities to film patient's stories to be shared via social media outlets. Please let us know if you may be interested in participating & we have your permission to contact you at a later date. (optional)
Occasionally we have opportunities to film patient's stories to be shared via social media outlets. Please let us know if you may be interested in participating & we have your permission to contact you at a later date. (optional)
Treatment Details
Type of Cancer (required)*
If Other, Type of Cancer (if applicable)
Treatment Facility (required)*
If Other, where are you being treated? (if applicable)
Oncologist/Treating Doctor Name*

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Adult Patient Sign Up

Patient Info

Household Info

Profile Info

Treatment Details

CareBOX Needs

Nutritional Supplements

Patient Acknowledgement:

Help us save lives by providing essential supplies to cancer patients.