Fund-A-Child (FAC) Application

Fund-A-Child (FAC) Application
Demographic Information
Patients Name

First NameLast Name
Patient Date of Birth

MonthDayYear
Date
Legal Guardian Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Ethnicity (optional):

Caucasian/WhiteAfrican American/BlackAsian/Pacific IslanderHispanicNative AmericanOther

List your monthly expenses below (bills or fees paid to whom and in what amount):
Expense
Amount
Expense
Amount
Expense
Amount
Expense
Amount
Expense
Amount
Expense
Amount
Expense
Amount
Expense
Amount
If additional space is needed, use the box below.

The completion of this application is not a guarantee for funding. Applications are approved on a case-by-case basis and subject to program availability. I understand that I am applying for subsidized services through a donor-funded program available at JSHC for either myself or a person under my care. I understand that intentionally falsifying information is grounds for termination of services and dismissal from the practice. By signing below I confirm that the information provided is true and accurate.
Parent/Legal Guardian Signature

Clear
Date

MonthDayYear
Date
Should be Empty:

Demographic Information