Prosthetic Eye Application

#addisfaith #endingchildhoodcancer

2410 Riverway Oak Drive I Kingwood, TX 77345
Guidelines for families seeking financial assistance

Applications are accepted from any child in the U.S. under the age of 18, any type of cancer diagnosis, and from all income levels. Warriors for West will consider grants to finance prosthetic eyes up to $4,000 per eye.

On the 2nd Monday of the month, applications are sent to AFF's Family Financial Assistance Committee to review. The committee meets on the 3rd Monday of the month to discuss and approve grant amounts.

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.
- 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
Application for Financial Assistance
Today's Date

MonthDayYear
Name of person completing this application
Relationship to patient
Child's Name
Child's Age
Child's Date of Birth

MonthDayYear
Gender
Child's Diagnosis
Date of diagnosis

MonthDayYear
Guardian 1 Name
Relationship to patient
Guardian 2 Name
Relationship to patient
Address
City
State
Zip
Phone Number
E Mail Address
example@example.com
How did you hear about Addi's Faith Foundation/Warriors for West?
Referral Name & Email
Patient Website (Caringbridge, Blog, Facebook, etc.)
Please state why you are requesting help from Addi's Faith Foundation/Warriors for West. We would love this chance to connect with your family and hear some of your story.
Please list how much assistance you are requesting.
Photo (This is not required, but we would love it!)

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Diagnosis/Treatment Confirmation Letter from social worker or oncologist

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Quote from Ocular Prosthesis Facility

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Quote from Physician

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Payment Information

Please ensure that the information provided below is correct and coincides with the estimate attached, as we will use these to make the direct payment to the facility.
Check payable to (Creditor):
Account number:
Creditor Address:
City:
State:
Zip:
Creditor Phone:
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:

Clear
*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.
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#addisfaith #endingchildhoodcancer

Application for Financial Assistance