Emergency Grocery

WPBDF's Emergency Grocery Assistance Application
Please read thoroughly, before proceeding:

The Western Pennsylvania Bleeding Disorders Foundation realizes hardship can strike at any time. This fund will provide gift cards for groceries, $100 per family member, up to $400 per family, for members who are in urgent need of food. This program is not intended to remedy chronic financial issues or supplement income on a regular basis.

If the household has already received grocery gift cards from the Fund in the current fiscal year (July 1-June 30), we ask that you reach out to a social worker at the Hemophilia Center of Western PA to discuss your situation and find out if other resources are available, before applying for another gift card. If you are not a patient of the Hemophilia Center of Western Pennsylvania, please reach out to Foundation Staff at 724-741-6160 or info@wpbdf.org for assistance. You will need to provide proof that additional resources were outreached before requesting another gift card.

Eligibility:
1. The applicant is a member of the Western Pennsylvania Bleeding Disorders Foundation with a bleeding disorder or lives in the same physical household as a person with a bleeding disorder.

2. The household income has significantly decreased and applicant is unable to pay essential household bills.

3. If the household has already received grocery gift cards from the Fund in the fiscal year (July 1-June 30), proof that additional resources were outreached before requesting another gift card is required. Applications will be reviewed on a case-by-case basis.

Application Process:
1. Answer all required questions on this form and submit the completed application.

2. A WPBDF staff member will review the application and outreach the applicant to confirm information. Staff may also share additional resources that may help the household.

3. When the application is approved, a grocery gift card will be mailed or emailed to the applicant for immediate assistance.

If you have any questions or need assistance filling out this form, please call the Western Pennsylvania Bleeding Disorders Foundation at 724-741-6160.
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
How would you like to be contacted?*

EmailPhone CallText Message
Has there been a significant change in income or a change in the size of your family? If yes, please explain and state when the change took place.*
How many adults live in the household*
How many children live in the household*
What is the dollar amount of the gift card you are applying for?*

$100 for 1 person$200 for 2 people$300 for 3 family members$400 for 4+ family members
What grocery store would you like a gift card for?*

AldiGiant EagleWalmartSave A LotOther
If a digital gift card is available for the grocery store you choose, would you like a digital gift card sent to your email?*

YesNoOther
What bleeding disorder does the affected family member have?*
Our funds are specifically for people affected by bleeding disorders. Can you tell us how you or your family member's bleeding disorder makes it difficult to access nutritious food?*
Please provide any additional information to support the reason you are applying for financial assistance for groceries.*
WPBDF Emergency Grocery Assistance Fund should be used as a payer of last resort and is not designed to address ongoing or chronic financial needs. Please indicate which of the following resources you have applied for or are currently using. If you have not applied for any of the resources listed, please select "None or Other" and briefly explain why, or provide the name of another resource you have used. (Select all that apply.)*

The Supplemental Nutrition Assistance Program (SNAP)Food PantryThe Emergency Food Assistance Program (TEFAP)Temporary Assistance for Needy Families (TANF)Senior Food Box ProgramWICNone or Other
If you have not utilized a food pantry, why not? (Skip to the next question if you have utilized a food pantry).
If you have utilized a food pantry, please share the name and location of the food pantry you utilize.
WPBDF patient assistance funds are intended to be used to help families manage financial stress due to a bleeding disorder; and therefore, our policy on distributing funds reflects this. We work closely with social workers from the Hemophilia Center of Western PA to ensure these funds are reaching patients in need, as a payer of last resort, and that patients are connected to other local resources and programs, as needed. This is one of the reasons why it is necessary to maintain regular clinic appointments: pediatric patients are typically seen 1-2 times a year, depending on their diagnosis, and adult patients are typically seen once a year or once every other year, depending on their diagnosis.

If you are not current on your clinic appointment and getting to the treatment center is a challenge for you, please know that funds are available to help you/your family members access care. Examples of transportation assistance include taxi fare, bus fare, and gas cards. For assistance with transportation costs, please contact a social worker at the HCWP (412-209-7280). During your appointment, HCWP staff can also help direct you to other specific resources that might benefit you.
Are you/your family member a patient of the Hemophilia Center of Western PA?*

YesNo

Enter the date of the last appointment at the Hemophilia Center of Western PA.*

Enter the name of your/your family member's medical provider that you see for bleeding disorder care, and the date of the last appointment. Your provider may help manage some of the medical concerns that are causing financial strain.*

Read the following statement and click the checkbox:*

I give WPBDF permission to verify my last hematology appointment date and, if needed, I agree to provide documentation of the last appointment date, upon request.
Read the following statement and click the checkbox:*

I declare that, to the best of my knowledge, the information provided is true; and I understand that any willful dishonesty may make me ineligible for future assistance.
By selecting the "I Agree" checkbox, I am signing this document electronically. I agree that my electronic signature is the legal equivalent of my manual/handwritten signature on this application for assistance.*

I Agree
Signature(Type your Full Name)*
Should be Empty:

WPBDF's Emergency Grocery Assistance Application