Apply for Help - Welcome Home Angel

Family Referral
Child's Information
Child's First Name*
Child's Last Name*
Child's Date of Birth*

MonthDayYear
Street Address*
City*
State*
Zip Code*
County*
Submissions outside WHA's service areas will be kept on file for future chapters to assist.
Family Information
Parent(s)/Guardian(s) Name:*
Relationship: You are the child's:*

Biological ParentLegal GuardianOther
If "Other" please explain:
Parent(s)/Guardian(s) Email*
example@example.com
Best Phone Number to Reach Parent(s)/Guardian(s*
Please enter a valid phone number.
Preferred Method of Communication*

Phone CallTextEmail
Do you live with the child on a full-time basis? If not on a full-time basis, we will request custody agreements and/or proof of custody.*

YesNoNot applicable
Child's Condition, Diagnosis, or Injury Information
Please give us your child's condition(s)/ diagnosis(es).*
If there are additional health considerations we should take into account, such as allergies, please explain them.
Healthcare Provider Information
Who is the best to consult with us about the child's condition and its effect on daily life in the home? This person will be contacted to confirm medical eligibility.*
Provider's Name
Provider Role*

Case Manager/Care CoordinatorMedical ProviderSchool ProfessionalSocial WorkerTherapist
Please provide a phone number for the above named person*
Please enter a valid phone number.
Please provide an email address (if available) for the above named person*
example@example.com
Please attach a photo of the child:*

Cancelof
How did you hear about Welcome Home Angel?*
Should be Empty:

Family Referral

Child's Information

Family Information

Child's Condition, Diagnosis, or Injury Information

Healthcare Provider Information