CareZ

Eligibility Requirement: The parent or guardian must be a U.S. citizen. Documentation (such as a birth certificate or U.S. passport) may be requested but can be provided at a later time if needed.

Today's Date

Date

Social Worker or Therapist Name

First NameLast Name

How long have you known this family?

Hospital Name or Therapy Center

Hospital or Therapy Center Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Social Worker or Therapist Email

example@example.com

Social Worker or Therapist Phone

Please enter a valid phone number.Format: (000) 000-0000.

Child's Name

First NameLast Name

Child's Name

Is this child a LightZ of Hope recipient?

Child's Birthday

Date

Primary Diagnosis

Secondary Diagnosis

If child is an in-patient, how long has the child been hospitalized?

Please specify in days, weeks, or months

Other

Parent or Legal Guardian Name

First NameLast Name

Parent or Legal Guardian Primary Language

Parent or Legal Guardian Email

example@example.com

Parent or Legal Guardian Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Child's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Number of children who are dependents (minors) living in the household:

Item Request or Grant

Grant

Item Requested

complete if you answered "Item" in the previous field

Approximate cost of item requested

If request is not granted

Other, please explain further:

What specific need is the family facing that makes financial assistance necessary?

Vendor #1

Complete this section if LightZ of Hope is purchasing an item for you.

Contact Person's Name | Vendor #1

First NameLast Name

Contact Person's Email | Vendor #1

example@example.com

Contact Person's Phone Number | Vendor #1

Please enter a valid phone number.Format: (000) 000-0000.

File Upload

Vendor #2

Complete this section if LightZ of Hope is purchasing an item for you.

Contact Person's Name | Vendor #2

First NameLast Name

Contact Person's Email | Vendor #2

example@example.com

Contact Person's Phone Number | Vendor #2

Please enter a valid phone number.Format: (000) 000-0000.

File Upload

Please list three additional resources which you have applied for financial assistance for the patient’s family including the dates the applications were submitted and the status of the applications (Pending or Denied). If denied, please provide the denial letter below.

Denial Letter Upload

Contact Person's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

If applicable, please include any eviction notices or utility cut off notices.

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