Request Assistance Form

Email*

example@example.com

Child's Name: When entering your childs name, please do not use any symbols. Our system does not recognize special characters.*

First NameLast Name

Legal Guardian/Parent's Name: (must match drivers license provided)*

First NameLast Name

Cell Phone Number*

Please enter a valid phone number.

Have we helped your child before?*

YesNoI have another child who has received or is currently receiving assistance from Meredith's Miracles.

What is your other child's name?

Is your child on Medicaid?

YesNo

Is your child female or male?

FemaleMale

Are you both the child's Legal Guardian AND Custodial Parent?*

YesNoSocial workerOther

If you are a Social Worker filling this out for a family, enter your Social Worker Pin Number. *

Child's Date of Birth (Ages must be Birth-18 years old)*

MonthDayYear

We have 3 methods of funding. Which one would you like to use?*

Direct Deposit (ACH Transfers): Upon submitting your application, you will receive an email prompting you to complete our Direct Deposit ACH Authorization Form. This setup is required only once, unless there are changes to your banking information.Check: A check will be mailed to your home address and issued in the name of the Legal Guardian or Parent specified on this form.Cash App: This option is available for emergencies cases or if you do not have a bank account for Direct Deposits.

CASH APP: If selecting Cash App list above your Cash App tag "$cashtag". *Please double check this information! We are not responsible for funding that is not received if the information is put in incorrectly.*

Home Address *

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

In which county is your residence located? Please be aware that to be eligible for assistance, your current home must be situated in one of the counties mentioned below. We kindly ask that you refrain from applying for funding if you do not reside within our designated coverage area. Providing false information may result in legal consequences.*

Type of Assistance you need? *

Please select EMERGENCY for our system to alert us. We are available on call 24/7, so ensure that this is a TRUE emergency before paging us outside of regular hours..*

EMERGENCY!!!!! *Examples include life flight, ambulance, or an emergency trip outside of your area.

Paperwork/Transportation for your Emergency:

Airlifted/Ambulance Emergency Travel: If your child is being airlifted or transferred by ambulance, it is essential to provide a copy of the transfer paperwork. This documentation should include details about the facility from which the child is being transferred from and the facility to which they are being transferred to.Emergency Travel by Personal Automobile : If you have not visited your local emergency room and the out-of-area facility you are traveling to requires your child to be expedited, please ensure that an admission bracelet is sent to us upon arrival.

What type of surgery is your child scheduled to undergo?

Recurring Cancer Treatment:

We know the amount of cancer treatments per month can accumulate fast. To save you time and cut back on the amount of times you have to apply, we've updated our application to allow you to only have to apply once a month. If you have 3 appointments or less scheduled this month, go back above and change your assistance type to "Doctor Appointment," and apply per trip.

**NICU Families: Important Funding Information**

NICU families are required to submit this form monthly, along with the social worker referral form, to confirm that your baby remains hospitalized. To qualify for monthly funding while your child is in the NICU, at least one parent must either stay at the bedside or visit four or more times each month.

Funding Denied: Please note that families who do not meet these requirements will not be approved for funding if at least one parent is not present at the bedside or visits the NICU four or more times per month.

**Notice Requirement for Trip Funding**We kindly request a minimum of two weeks' notice before your trip, unless it is classified as an unexpected medical trip. This notice period allows us to arrange funding in advance and also gives us the opportunity to address our emergency cases. Please be aware that applications submitted with less than two weeks' notice may be denied, especially if the appointment has been scheduled for some time and the application was made at the last minute. We completely understand if you did not receive two weeks' notice from the doctor or if there are urgent needs for your child that fall within this timeframe. In such cases, please provide a detailed explanation in your trip details. Thank you for your understanding.*

I am submitting my "Application for Assistance" Form and will get my social worker to fill out the "Medical Staff Referral" Form 2 weeks prior this trip.This is deemed an UNEXPECTED medical trip. I did NOT receive two weeks' notice. I will submit this application immediately and request that my social worker complete the "Medical Staff Referral" form ASAP.

Request Assistance Form

Appointment Section