Application for Financial Assistance

Guidelines for families seeking financial assistance

Applications are accepted from any child in the U.S. being treated at a select hopspitals who are under the age of 18, have any type of cancer diagnosis, and from any income levels. Although Addi's Faith Foundation strives to help as many families as possible, we simply cannot meet every request and priority is given to Houston area, brain tumor patients, with a high financial need. AFF will consider grants up to $2,500.

On the 2nd Tuesday of the month, applications are sent to AFF's Family Financial Assistance Committee to review. The committee meets on the 3rd Tuesday of the month to discuss and approve grant amounts. Payments are made directly to the creditor within 2 weeks.

For your application to be reviewed, you must submit the following:

Application that is thoroughly completed by a parent or legal guardian. The more information you can provide the better. (Incomplete applications will not be reviewed.)
A patient confirmation letter from your doctor or licensed social worker on letterhead explaining the child's diagnosis, family situation, and treatment plans for the next 60 days.
Bills or account statements for which you are requesting assistance. AFF cannot apply funds to credit cards or medical bills.
Child's photo. This is not a requirement, but we love to put a face with the name.

For more information, please email: info@addisfaith.org

Today's Date

Name of person completing this application

Relationship to patient

Child's Name

Child's Last Name

Child's Age

Child's Date of Birth

Gender

Child's Diagnosis

Date of initial diagnosis

Relapse date (if applicable)

Guardian 1 Name

Relationship to patient

Guardian 2 Name

Relationship to patient

Address

City

State

Zip

Phone Number

Format: (000) 000-0000.

E Mail Address

example@example.com

How many members are living in the household?

Please list their names and ages:

How did you hear about Addi's Faith Foundation?

Social Worker's Name & Email Address

Referral Name (if not a social worker)

Patient Website (Caringbridge, Blog, Facebook, etc.)

Where is your child receiving treatment?

Where is your child being treated?

Approximately, how far is the treatment site from where you live?

If you travel for treatment, where do you reside during your stay?

Please state why you are requesting help from Addi's Faith Foundation. We would love this chance to connect with your family and hear some of your story. (AFF will consider requests up to $2,500, which will be paid to the creditor directly.)

Prior to diagnosis

Current Income

SSIChild SupportSalaryOther

Guardian 1: Employer

Guardian 2: Employer

YesNo

List any additional organizations you have received assistance from.

Photos or Videos of Your Child (This is not required, but we would love it!)

Diagnosis/Treatment Confirmation Letter

Recent mortgage statement, copy of lease agreement, and/or car loan(s):

If any other accounts are past due, please attach below:

Payment Information

Please ensure that the information provided below is correct and coincides with the bills attached, as we will use these to make the direct payment to the creditor.

**Grants can not be issued until this is provided.** Please list bill pay information: business name (check payable to), address, and account number. If attached bills include this information, please still confirm it here.*

Financial assistance is sent to businesses directly, PLEASE DO NOT LIST PARENTS' NAME ABOVE.

Business name of attached bill (check payable to):*

Financial assistance is sent to businesses directly, PLEASE DO NOT LIST PARENTS' NAME ABOVE.

Account number:*

Creditor/Business Address:*

City:

State:

Zip:

Creditor Phone:

Format: (000) 000-0000.

I understand that by signing this application, I give consent to Addi's Faith Foundation to disclose to the public via television and radio stations, newspapers, websites, magazines, newsletters, social media, as well as in educational and fundraising opportunities, my child's/my family's story including child diagnosis, general story, photos, and videos. I authorize the verifier (healthcare provider, social worker etc. provided on this form to release information (including diagnosis, treatment status and other pertinent information related to grant request) to Addi's Faith Foundation as necessary to determine eligibility and processing of this grant request. I understand that my personal information will not be published or shared with the public or a third party. Personal information is defined as home address, phone number, email address and creditor information.*

Please print name.

Signature:*

*Anti-Discrimination Policy: You and your child will not be discriminated against or denied assistance because of your race, religion, color, national origin, gender or political affiliation. All financial applications will be reviewed on a case-by- case basis and final determination will be made based upon your eligibility, AFF guidelines and the availability of funds.

Application for Financial Assistance

Family Income