Leaving Imprints Application

2024 Leaving Imprints Application

Leaving Imprints is a non-profit, 501(c)3 foundation that is dedicated to charitable purposes and focused on families of children with special needs and any other general charitable purposes.

ELIGIBILITY

Individuals applying for a Leaving Imprints scholarship must be the parent or legal guardian of the child with special medical needs who is in need of financial assistance. Applicants must demonstrate a financial need for assistance.

AWARD CRITERIA

1. Completed Application: Applications submitted with missing information will not be considered.

2. Copy of formal medical diagnosis

3. All applicable supporting financial documentation referenced in application.

4. A brief statement explaining why your family is requesting a scholarship from Leaving Imprints.

Financial Requirements:
1. Two years of full tax return - Must be either the two most recent years OR if the most recent year is not available, the two years prior PLUS financial information for the most recent year such as W2s, K1s, 1099s, etc. for all parents or legal guardians.

-If parents / legal guardians file separately, full returns are required for both.
Include all relevant pages, including any business or self employment information if you are unable to provide two years of full returns.
We will accept the tax return transcript from the IRS for the two most recent years. Include copies of W2s, 1099s, K1s and any other business income, self employment income, AGI income, investment dividends, etc.

2. Insurance documentation: We require a copy of the official Summary of Benefits and Coverage (SBC). (Sample included on the documentation page).
We will not accept a copy of an id card or other insurance information.

OUR PROCESS

Completed applications are submitted to the board for review. The board will evaluate each case based on the demonstrated need for financial assistance.

Scholarship recipients will be notified via email, or by phone if email is not available. Scholarship funds will be disbursed directly to the medical practice, wellness center, or other designated healthcare provider involved in the recipient's care.

Please note that all necessary medical releases and waivers must be signed to authorize the release of medical billing information to Leaving Imprints.
I have read and understand the requirements listed above and will include all information as part of this application.
Initial:*
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APPLICANT INFORMATION:
Child's Legal Name*
Gender*
Child's Date of Birth*
Child's Age*
Child's Street Address*
City*
State*
Zip Code*
Including yourself, how many people live in your household?*
PERSONAL INFORMATION:
Parent/Legal Guardian (1) Full Name*
Parent/Legal Guardian (1) Email Address*
example@example.com
Parent/Legal Guardian (1) Primary Phone Number*

Area CodePhone Number
Parent/Legal Guardian (1) Secondary Phone Number

Area CodePhone Number
Parent/Legal Guardian (1) Employer*
Parent/Legal Guardian (1) Current Annual Salary Income*
(If you do not file a tax return, please list your annual income)
Check this box if you are a business owner or receive other non-W2 income.
Parent/Legal Guardian (2) Full Name*
If this option doesn't apply, please type N/A
Parent/Legal Guardian (2) Email Address*
example@example.com *If this option doesn't apply, please type N/A
Parent/Legal Guardian (2) Primary Phone Number*

Area CodePhone Number.
Parent/Legal Guardian (2) Secondary Phone Number

Area CodePhone Number
Parent/Legal Guardian (2) Employer*
If this option doesn't apply, please type N/A
Parent/Legal Guardian (2) Current Annual Salary Income*
(If you do not file a tax return, please list your annual income) *If this option doesn't apply, please type N/A
Check this box if you are a business owner or receive other non-W2 income.
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SCHOLARSHIP REQUEST:
Please specify the healthcare facility or other institution where you require financial assistance.
Business/Organization Name*
Business/Organization Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Business/Organization Contact Name*

First NameLast Name
Business/Organization Phone Number*

Area CodePhone Number
SCHOLARSHIP AMOUNT REQUESTED:
This amount should reflect the total amount you are requesting.
Scholarship Amount Requested $*
Have you received a scholarship from Leaving Imprints in the past?*

YesNo
Please choose the option that best describes your request.*

Cash PayCovered by Insurance
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INSURANCE INFORMATION:
Please check all insurance coverages:*

MedicaidEmployer InsuranceChild-only PolicyOther
If you have NO insurance, check here.
COST TO COVER YOUR CHILD
Insurance Deductible:*
If you do not have insurance, please type N/A
Insurance Copay (if applicable)*
If not applicable, please type N/A
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PERSONAL STATEMENT:
Please provide a brief statement explaining why your family is requesting a scholarship from Leaving Imprints.*

0/750
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SUPPORTING DOCUMENTS
You MUST upload a copy of the SBC for the current plan year for the plan that will be covering the requested financial assistance. You can see a sample of the SBC here. This is a standard format approved by CMS. If you do not have this document or need assistance getting a copy, you should call the customer service number on your medical ID card and ask for your plan’s official “summary of benefits and coverage".
SBC

Upload a File

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Out of Pocket Max*
Please share and/or attach any information citing efforts you have sought on behalf of this child to provide funding (e.g., applications for health insurance, applications for other scholarships and/or grants, negotiated discounts with providers, etc.)

Upload a File

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List Information citing efforts attached above.
For individuals seeking financial assistance for the treatment of their child, please be sure you have completed and included the following:
Copies of complete tax returns with all schedules and Addendums for the last two years.

Sample photo of 1040

Sample photo of Tax Transcript
First Year Tax Returns

Upload a File

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Second Year Tax Returns

Upload a File

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If tax returns are not available for the most recent year, you must also include copies of W2S, 1099S, K1 and all other income related documentation for the most recent year.
W2S, 1099S, K1

Upload a File

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Copy of insurance policy or policies

Upload a File

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Copy of diagnosis

Upload a File

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APPLICANT ACKNOWLENDGEMENT:
With the submission of this application, the applicant, in their individual capacity and, if applicable, as representative as legal guardian of a child understands:
- A complete application and the requested documents are necessary to be considered for financial assistance.
- There is no guarantee of financial assistance.
- Scholarships are awarded in a manner that ensures fiscal responsibility by Leaving Imprints. Decisions are made on a case-by-case basis by the Leaving Imprints Board of Directors.
- Any amount awarded is based on the foundation’s evaluation of the application and documentation, and the amount of funds available to the foundation at the time of the request.
- Any scholarship awarded to the applicant will be paid directly to the medical provider/healthcare facility or to an insurance company to pay for premiums for the applicant. No monies will be paid to an applicant.
I have read and understand the requirements listed above and will include all information as part of this application.
In addition, if an applicant is awarded a scholarship on behalf of Leaving Imprints, the recipient must adhere to the following guidelines and stipulations:
- If any information provided within this application changes, the applicant will supplement the application with the updated information immediately upon receiving said information, e.g., change in health insurance coverage, change in financial circumstances, change in healthcare provider as noted in this application.
- If the applicant’s need for requested funds ceases prior to donated funds being utilized, the applicant will notify Leaving Imprints immediately and arrangements will be made with the healthcare provider, institution, or sponsoring conference/organization to return all unnecessary funds.
- Scholarship funds are available only for the calendar year which they are approved for. Unused funds will not roll over to future years
I have read and understand the requirements listed above and will include all information as part of this application.
If awarded a scholarship, the recipient agrees to allow Leaving Imprints to use the name of the recipient, pictures of recipient, and/or statements provided by the recipient on our Leaving Imprints website, promotional videos, and material that advertises and promotes the foundation.*

I consentI do NOT consent
I declare the information provided is within my personal knowledge and is true and correct. I understand failure to provide true and correct information may result in my application not being processed, the loss of any current and/or future funding and other penalties. Further, I understand I must adhere to the guidelines and requirements within this application and failure to do so may result in the loss of any current and/or future funding opportunities provided by Leaving Imprints.
Signature of Applicant*

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