Elmhurst Children's Assistance Foundation

PersonalOrganization
Person Completing Form*

First NameLast Name
Relationship to Applicant*
Date of Application

MonthDayYear
Date
Applicant Information
Organization Information
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Date of Birth*

MonthDayYear
Age*
School Attending*
Medical condition and/or disability*
Please include letter of medical condition or disability from medical professional
Organization*
Website*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Contact*

First NameLast Name
Phone Number*

Area CodePhone Number
E-mail*
Amount Requested*
ECAF Reference*
YesNo
Who will benefit from this money?*
What percentage of your target population is local to Elmhurst?*
What are the other sources of funding for you organization?*
How long has your organization been in existence?*
How will the use of these funds fit ECAF's mission?*
ECAF's goal is to assist families who have a connection to, or reside in our community, where a child's life is impacted by a serious medical or disabling condition.
Please itemize how the funds will be utilized:*
What are the specific results your organization hopes to achieve with these funds?*
How will your organization recognize/advertise ECAF if funds are approved?*
When do you need the funds by?*

MonthDayYear
Date
Parent/Guardian Information
Name*

First NameLast Name
Relationship to Applicant*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Present Occupation*
Occupation Start Date*

MonthDayYear
Home Phone*

Area CodePhone Number
Mobile Phone*

Area CodePhone Number
Email*
Net Worth Worksheet
Assets
Personal Possessions*
Car(s)*
Home Value*
Savings & Investments*
Life Insurance (Cash Value)
Stocks/Bonds/Mutual Funds/CDs (Total Value)
Retirement Savings 401K's, IRA's (Total Value)
Total Assets*
Liabilities
Home Loan*
Car Loan*
Credit Card Debt*
Personal Loans*
Unpaid Bills*
Other Debts*
Investment Debts*
Business Loan*
Investment Loan*
Total Liabilities*
Total Net Worth
Assets minus liabilities.*
Financial Assistance Request Information
Purpose for requesting financial assistance*
Please be specific.
What is the total amount of assistance you are requesting?*
Please be itemize and upload documents below substantiating the amount of your request.
Assistance Documents*

Upload File(s)

Cancelof
Retirement Savings 401K's, IRA's (Total Value)*
Who is your primary health insurance provider?*
Please be specific.
Who is your secondary health insurance provider?*
If applicable.
Do you have any additional sources of financial assistance?*
Example: Labor Unions, Social Clubs, etc.
Please provide required documents
Elmhurst Residency or Employment*

Upload a File
Please upload your proof of residency and employment in Emlhurst. Cancelof
Tax Forms*

Upload a File
Please upload your most recent tax form or W-2 form. Cancelof
Medical Recommendation*

Upload a File
Please upload a letter from a medical professional confirming the medical diagnosis of applicant. Cancelof
How did you learn about Elmhurst Children's Assistance Foundation?
Source*
Please specify other source.*
Select board member.*
Name of school professional.*
Name of medical professional.*

Applicant Information

Organization Information

Parent/Guardian Information

Net Worth Worksheet

Assets

Liabilities

Total Net Worth

Financial Assistance Request Information

Please provide required documents

How did you learn about Elmhurst Children's Assistance Foundation?