Cancer patients living in Vermont can apply for the Maggie Card to receive discounts on products and services from participating local businesses.

To apply, fill out and submit this form. Please allow 1-2 weeks to process your request and receive your card in the mail.

Have questions? Contact us.

Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Email

Cancer Diagnosis Date

Cancer Type

I give permission for CPSF to email me regarding program updates and new participating businesses.