Â
Print
Save
Submit
Unique Just Heart Case ID
Application Status
Please Select
Approved
Denied
Incomplete
In Progress
Application Status Approve/Disapprove Date
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Case Status
Please Select
Open
Closed
TOTAL MONTHLY INCOME
TOTAL MONTHLY EXPENSES
TOTAL ASSETS
TOTAL DEBTS
Notes
Welcome!
Thank you for considering Just Heart Foundation for support during this challenging time. As a small nonprofit, our application process is highly selective, and while we aim to assist as many families as possible, we cannot guarantee approval for every application. To be considered, please complete your application thoroughly and provide detailed information about your financial situation before and after your child’s medical crisis, as well as any plans for regaining stability.If approved, we invite you to pledge support for future families by raising funds through a personalized fundraiser link we provide or other means. This voluntary effort helps sustain our mission to assist families in need.We appreciate your understanding and cooperation.Should you have any questions, you may email us at contact@justheart.org
*
I HAVE READ AND UNDERSTAND
Before you begin, we recommend gathering the following information:
Back
Next
Save
Your Information
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Primary Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Secondary Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Other Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Gender / Sex
Please Select
Male
Female
N/A
Resident Status
*
Please Select
US Citizen
Lawful Permanent Resident
Race
Please Select
White
Native American or Alaska Native
Asian
Asian Indian
Black or African American
Native Hawaiian or Other
Hispanic or Latino
Marital Status
*
Please Select
Married
Divorced
Single
Widowed
Military Status
Please Select
N/A
Active Duty
Reserves
Retired
Last 4 Digits of SS#
*
Back
Next
Save
Co-Applicants
Co-Applicant 1
Co-Applicant 2
Back
Next
Save
Housing
Housing Status
*
Please Select
Owner
Renter
Other
Number of Adults in Household
*
Number of Children in Household
*
Number of Dependents Under 18 in Household
*
Number of Dependents Over 18 in Household
*
Number of Non-Dependents in Household
*
Back
Next
Save
Family
Number of Parents
*
Please Select
1 Parent
2 Parents
Number of Children
*
ADD FAMILY MEMBERS:
Child’s Medical Condition
*
Please Select
Heart
Autism
Transplant
Cancer
NICU
Accident
Other
Back
Next
Save
Employment
Employment Status
Please Select
Employed Full-Time
Employed Part-Time
Unemployed
Employer 1
Employer 2
Employer 3
Previous Employer
Please upload a picture of your latest pay stub:
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Back
Next
Save
Finances
Monthly Household Income Information
Salary / Wages
*
Alimony / Child Support
Rental Income
Self-Employment Income
Pension
Retirement
Social Security Disability
Social Security Income
Unemployment
Other Income
Monthly Household Living Expense Information
Monthly Mortgage / Rent
*
Utilities (Total of Power / Gas / Water / Trash)
*
Phone
Cable / Satellite / Internet
Insurance
Child Care Expenses
Car Payments
Child Support / Alimony
Other Living Expenses
Household Asset Information
Current Checking Account Balance
*
Current Savings Account Balance
*
Value of Automobiles
Home Value
Household Liability and Debt Information
Mortgage Loan Balance
Auto Loan Balance
Student Loan Balance
Credit Card Loan(s) Balance
Back
Next
Save
Additional Information
Social Worker
*
First Name
Last Name
Social Worker Email
*
example@example.com
Social Worker Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Primary Pediatrician
First Name
Last Name
Name of Practice
Pediatrician Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Pediatrician Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Institution Name
Please Select
Children's Healthcare of Atlanta
Children's Hospital of Alabama
Children's at Erlanger
Sibley Heart Center
Marcus Autism Center
Other
If other, please name Institution
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Do you have Medical Insurance?
*
Please Select
Yes
No
Insurance Company
Are you receiving assistance from any other organization?
*
Please Select
Yes
No
If yes, please provide details
Have you ever filed bankruptcy?
*
Please Select
Yes
No
If yes, please provide details
Back
Next
Save
Our Story
*
Family or Child Photo:
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Were you self-sufficient before your medical crisis?
*
Will a grant of this kind return you to self-sufficiency?
*
Please briefly describe how.
0/0
How will you maintain this self-sufficiency once the grant has expired?
*
0/0
Back
Next
Save
Ready to Review? Click the review answers button below...
Save
Submit
Should be Empty: