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Application For Financial Assistance
Please fill out this form and click the “Submit” button at the bottom of the page. If the form doesn’t submit, please check that you filled in all the required fields.
*
Indicates required field
Parent #1
Name
*
First
Middle
Last
Suffix
Primary Phone Number
*
Email Address
*
Social Security Number
*
Preferred Contact Method
Phone
Email
Postal Mail
Address Where You Receive Mail
*
Street Address
City
State / Province / Region
ZIP / Postal Code
Employer
*
Annual Income
*
Please Attach Pay Stub
Drop files here or
Select files
Max. file size: 256 MB.
Marital Status
Married
Unmarried
Parent #2
Name
First
Middle
Last
Suffix
Primary Phone Number
Email Address
Social Security Number
Preferred Contact Method
Phone
Email
Postal Mail
Address Where You Receive Mail
Street Address
City
State / Province / Region
ZIP / Postal Code
Employer
Annual Income
Please Attach Pay Stub
Drop files here or
Select files
Max. file size: 256 MB.
Child
Name
*
First
Middle
Last
Suffix
Date of Birth
*
MM slash DD slash YYYY
Medical Condition/Diagnosis (please document)
*
Estimated Annual Cost of Other Related Expenses
*
Expected Duration of Medical Hardship
*
Estimated Annual Cost of Medical Care
*
Household
Total Monthly Recurring Expenses
*
Monthly Housing Payment
*
Other Monthly Expenses
*
Estimated Disposable Monthly Income
*
Estimated Expense Incurred Due to Medical Issue
*
Health Insurance Provider
*
Other Financial Assistance Available?
Cash Savings
*
Family
Tell us about your family, how many children live in your household, your child's medical condition and specific needs, and anything else you feel the foundation should know as your request for financial assistance is considered (please use reverse side of application if necessary).
*
Agreement
Please Read and Confirm
*
I certify that all statements made by me in applying for assistance are complete and true.
Signature Parent #1
*
Your printed name counts as your signature.
Date
*
DD slash MM slash YYYY
Parent #2 Signature
Date
DD slash MM slash YYYY
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