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Application for Assistance Form
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Applicant Information:
Child's Name
*
First
Last
Date of Birth
*
Date Format: MM slash DD slash YYYY
Diagnosis Information:
Diagnosis
*
Diagnosis Date
*
Date Format: MM slash DD slash YYYY
Doctor
*
Treatment Facility
*
Type of Treatment
*
Parent/Guardian Information:
Name
First
Last
Home Address
*
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Home Phone
*
Email
*
How long have you lived there?
*
Do You
*
Own
Rent
Monthly Mortgage/Rental Payment
*
Employment Information
Current Employer
How long have you been employed there?
*
Phone
*
Cell Phone
Fax
Position
*
Salary
*
Per
*
Month
Year
Supervisor's Name
*
First
Last
Other Income Source
Amount (Other Income Source)
Spouse/Significant Other (Living in same residence)
Name
First
Last
Employment Information (Spouse/Significant Other)
Current Employer
How long has he/she been employed there?
Phone
Position
Salary
Per
Month
Year
Supervisor's Name
First
Last
Other Income Source
Amount
Sibling Information
Siblings
Name
Age
Monthly Expenses
Monthly Expenses (in addition to rent/mortgage)
*
Expense Type
Amount
Other Financial Assistance
Is applicant/child covered by insurance?
*
Yes
No
Name of Insurance
Has money been raised on behalf of this applicant?
No
Yes
If yes, how much?
Has there been assistance from other organizations?
*
No
Yes
If yes, organization name.
Type of assistance
I authorize Give Hopeto share this application with other charitable organizations that may also be able to provide assistance.
*
Yes
No
Financial assistance requested (please prioritize)
*
What impact has this diagnosis had on your current income or financial situation?
*
What other financial resources do you have access to, or are you aware of that may assist you with treatment or other related costs?
*
Explanation of Emergency Situation
*
The Give Hope Foundation has authorization to use photographic images of the applicant.
*
Yes
No
You need not check ‘yes’ to be considered for support from The Give Hope Foundation.
Please attach any supporting documentation you would like us to review.
How did you learn about The Give Hope Foundation?
*
Electronic Signature
*
Please type your full name to agree to and accept Give Hope's terms and conditions and to complete this application.
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