Gas Card Request Form

Family Support Grant

Financial Assistance Application
To apply for financial assistance from the Love, Chloe Foundation, please complete and submit the following application along with the required accompanying documents. Grants are subject to the availability of funds. Applications are reviewed by our Family Support Council approximately once a month. You will be contacted by the Love, Chloe Foundation following review of your application.

Qualifications

• Any Kansas family with a child diagnosed with cancer prior to the child’s 18th birthday is eligible for consideration.

• The applicant must be the parent or legal guardian of the diagnosed child and the primary caregiver of the child. Family must be a Kansas resident.

• The application must be accompanied by a signed letter from the child’s treating physician on the physician’s letterhead stating the child’s full name, date of birth and diagnosis.

• All sections of the application must be completed, and all accompanying documents must be submitted in order for our Family Support Council to review the request. Failure to provide complete information is a basis for denial of an application.

• Assistance may be requested one time during any 12-month period. Each request for assistance requires submission of a new application.

Please contact Heidi Feyerherm-Smith at (785) 342-5534 or heidi@lovechloe.org if you have any questions concerning the application process.
Name of person requesting the grant*

First NameLast Name
Relationship to the child*
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Child's Information
Child's Name*

First NameLast Name
Date of birth*

MonthDayYear
Child's date of birth
Social Security #*
Diagnosis*
Diagnosis Date*

MonthDayYear
Date of diagnosis
Website where the child's journey is being shared
Facebook page, Caringbridge, GoFund Me, etc.
Hospital *
Hospital where you receive treatment
Physician*
Name of treating physician
Physician's Phone Number
Please enter a valid phone number.
Physician's Email Address
example@example.com
Financial Assistance can be requested every 12 months.
Have you received a Love, Chloe Financial Support Grant previously*

YesNo
What date did you receive your grant*

MonthDayYear
Please complete the following:*

I confirm that I am my child’s primary caregiver and that as a result of a severe economic hardship due to my child’s cancer, my family has suffered a short-term emergency need for assistance with basic necessities such as food, clothing, housing, transportation and medical assistance.Financial assistance from the Love, Chloe Foundation would help provide needed support in order for my family to have basic necessities such as food, clothing, housing, transportation and medical aid.
Amount Requested (up to $1,500)*
Please enter amount requested
The funds requested will be used as follows:*
Please indicate how you will be using the assistance funds.
How did you hear about Love, Chloe Financial Support Grant?*
Please submit a letter of verification from your hospital*

Letter must be from the treating institution on their letterhead. The letter must include the child's full name, diagnosis and date of diagnosis. Letters can be from the treating physician, nurse, social worker or child life specialist.
Cancelof
I acknowledge the following:*

I authorize the Love, Chloe Foundation and its agents and representatives to contact the above named medical institution and physician in order to verify my child’s cancer diagnosis.I attest that the information provided above and accompanying this application is true and correct to the best of my knowledge.
Permission for the Love, Chloe Foundation and its representatives to use photographs, audio recordings, letters, survey information or video recordings of my child or myself, our names and my child’s story to inform families, volunteers, the media and the general public about the Love, Chloe Foundation and its programs, services and events. Such materials may be used in, among other items, promotional materials, newsletters or on the foundation’s web site. If permission is granted, I, for myself and my child, release all claims against the Love, Chloe Foundation and its representatives with respect to copyright ownership and publication, including any claim for compensation related to use of these materials.*

I AgreeI Do Not Agree
Signature

Clear
When will you receive your grant?

Grant applications are reviewed monthly. You will be notified by email or phone when your request is received and approved! Approval of requests is dependent on the availability funds.
Should be Empty:

Family Support Grant

Child's Information

When will you receive your grant?