Financial Assistance

Name of Child: Age Now:

Sex: Male Female Diagnosis:

Date of Diagnosis:

Age When Diagnosed:

Doctor:

Doctor's Phone:

Social Worker:

Social Worker's Phone:

As a result of our child's illness, we have encountered difficulties in meeting our expenses and are seeking assistance for the following bills (please submit copies of all bills you are seeking assistance with: .

Please provide us with your contact information so that we may be able to contact you to discuss the application further.

Mother's Name: Occupation:

Phone #: Cell Home

Father's Name: Occupation:

Phone #: Cell Home

Email Address:

Streeet Address:

City: State: ZIP:

Please use the following space to include any extenuating circumstances that you feel may be relevant to your request: current financial status, current employment status, family situation, etc.

Has your family sought financial assistance from other organizations?
If so, which organization(s)?
Date Applied:
Assistance Granted?: Yes No

Signature of Parent or Guardian: