Kerrington's Heart Christmas Giving Application

2024 Christmas Giving Application

Deadline - Saturday November 30, 2024
This application for Christmas assistance may be submitted for any child who is under the age of 18, suffering from a congenital heart defect (CHD), and whose permanent residence is in the state of Kentucky. Siblings of a child suffering from CHD are also eligible under the same application.
I understand that in order to be eligible for the Christmas Giving Program, my family MUST be experiencing a financial hardship as a result of expenses incurred within the last 6 months due to a hospitalization related to my child's CARDIAC diagnosis.
All applicants MUST upload the following documentation at the bottom of this form before submitting. Incomplete applications will NOT be considered. (Please read carefully)

1. Proof of Kentucky residency (driver’s license, lease, mortgage statement, utility bill, etc. which lists your name and address)2. Verification of all children being registered, showing their date of birth (current Medicaid card, birth certificate, shot records, school records). This can also be proof that you are the parent or legal guardian, if your name is on it.3. Income verification for the past 30 days for ALL household members (Paycheck stubs, a letter of verification from KTAP, Social Security, SSI, proofs of child support)4. Expense verification for the past 30 days for ALL household members. (Copies of all monthly bills)5. Referral letter from a hospital Social Worker confirming medical eligibility.6. You MUST list all clothing size, 1 or more needs, and a minimum of 3 wish items for each child (electronics such as phones, iPads, gaming devices, etc. are NOT recommended)
Applicant Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Applicant's Relation to the Child*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Child 1 (CHD Child)*

First NameLast Name
Gender*
Child's Date of Birth*

MonthDayYear
Date
Briefly describe child's medical condition *
Name of Cardiologist*

First NameLast Name
Name of Social Worker

First NameLast Name
Is your child currently hospitalized?*

YesNo
When was their last hospitalization?*

MonthDayYear
Date
Hospital
Shirt Size
Pant Size
Coat Size
Shoe Size
What are the child's NEEDS:
List a minimum of 3 WISH items:
Add a child?

YesNo

Child 2 Name

First NameLast Name
Gender
Date of Birth

MonthDayYear
Date
Shirt Size
Pant Size
Coat Size
Shoe Size
What are the child's NEEDS:
List a minimum of 3 WISH items:
Add a child?

YesNo

Child 3 Name

First NameLast Name
Gender
Date of Birth

MonthDayYear
Date
Shirt Size
Pant Size
Coat Size
Shoe Size
What are the child's NEEDS:
List a minimum of 3 WISH items:
Add a child?

YesNo

Child 4 Name

First NameLast Name
Gender
Date of Birth

MonthDayYear
Date
Shirt Size
Pant Size
Coat Size
Shoe Size
What are the child's NEEDS:
List a minimum of 3 WISH items:
Add a child?

YesNo

Child 5 Name

First NameLast Name
Gender
Date of Birth

MonthDayYear
Date
Shirt Size
Pant Size
Coat Size
Shoe Size
What are the child's NEEDS:
List a minimum of 3 WISH items:
Add a child?

YesNo

Child 5 Name

First NameLast Name
Gender
Date of Birth

MonthDayYear
Date
Shirt Size
Pant Size
Coat Size
Shoe Size
What are the child's NEEDS:
List a minimum of 3 WISH items:
Add a child?

YesNo

Child 6 Name

First NameLast Name
Gender
Date of Birth

MonthDayYear
Date
Shirt Size
Pant Size
Coat Size
Shoe Size
What are the child's NEEDS:
List a minimum of 3 WISH items:
Add a child?

YesNo

Child 7 Name

First NameLast Name
Gender
Date of Birth

MonthDayYear
Date
Shirt Size
Pant Size
Coat Size
Shoe Size
What are the child's NEEDS:
List a minimum of 3 WISH items:
Add a child?

YesNo

Child 8 Name

First NameLast Name
Gender
Date of Birth

MonthDayYear
Date
Shirt Size
Pant Size
Coat Size
Shoe Size
What are the child's NEEDS:
List a minimum of 3 WISH items:
Add a child?

YesNo

Child 9 Name

First NameLast Name
Gender
Date of Birth

MonthDayYear
Date
Shirt Size
Pant Size
Coat Size
Shoe Size
What are the child's NEEDS:
List a minimum of 3 WISH items:

Upload Documentation Here

Cancelof
By signing below, I confirm that the above information is true and accurate to the best of my knowledge. I also understand that completing this application does not guarantee program eligibility. All required documentation must be received, as stated above, for my application to be considered. Kerrington’s Heart may request additional information necessary to determine my eligibility. If any of the above information is found to be untrue or falsified, I understand my application will be denied and I may be ineligible for future assistance. By completing this application, you are giving permission for a member of Kerrington’s Heart to contact you.
Please allow up to 7 business days for our team to review your application. We will notify you of our decision (approval or denial) via email. Sometimes important emails can accidentally end up in your spam or junk folder. To avoid missing our response, please check these folders regularly while you wait.
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2024 Christmas Giving Application