Elmhurst Children's Assistance Foundation

What type of assistance?

Personal Organization
Person Completing Form *

First Name Last Name
Relationship to Applicant *
Date of Application

Month Day Year
Date
Applicant Information
Organization Information
Name *

First Name Last Name
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Date of Birth *

Month Day Year
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

City State / Province

Postal / Zip Code Country
Contact *

First Name Last Name
Phone Number *

Area Code Phone Number
E-mail *
Amount Requested *
ECAF Reference *
501(c)3 Status? *

Yes No
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? *

Month Day Year
Date
Parent/Guardian Information
Name *

First Name Last Name
Relationship to Applicant *
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Present Occupation *
Occupation Start Date *

Month Day Year
Home Phone *

Area Code Phone Number
Mobile Phone *

Area Code Phone 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)

Cancel of
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 *
Please upload your proof of residency and employment in Emlhurst.
Tax Forms *
Please upload your most recent tax form or W-2 form.
Medical Recommendation *
Please upload a letter from a medical professional confirming the medical diagnosis of applicant.
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?