Survivors of Violence Foundation Treatment Application

Survivors of Violence Foundation Treatment Application

All Applications are reviewed on a case-by-case basis to support the Foundation's mission of providing reduced cost or no cost treatments and care for individuals in need.
Checklist for submitting an application:
- Ensure all sections of the application are completed.
- A copy of your previous year tax return for all in household
- Your signature/date is required on the last page.
- Submit a photo of your governmenet issues ID (Driver's license, State ID, Military ID, etc.)
Name*

First NameLast Name
SSN: (Last 4 digits only)*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth*

MonthDayYear
Date
Gender*

MaleFemaleNon-binary
Number of people in household (Including self)*
Total monthly income*
Upload most current copies of income documentation for you and all dependent persons. Acceptable documents include: tax returns, pay stubs, or benefits award letters.*

Cancelof
Physicians Name*

First NameLast Name
Physicians Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Treatment You Are Seeking*

Scar ImprovementNon-Healing Wound CareOther
Describe treatment you are seeking.*
List any previous treatment you have received for the condition you are seeking financial assistance through the foundation.
Please explain the circumstances that have caused you to apply for treatment through the foundation. Please explain why this will improve your quality of life. Be as detailed as possible; use an additional sheet of paper if necessary, or write on the back of this application. A committee reviews your application and the more information you can provide for better understanding of your need, will assist in making a determination for your treatment.*
Have you ever been in a physically abusive relationship?*

YesNo
Have you currently in a physically abusive relationship?*

YesNo
Have you currently working with a shelter, social worker, or therapist?*

YesNo
Provide the name and contact information for your shelter, social worker, or therapist.
Have you ever been affiliated with a gang?*

YesNo
The foundation will not accept individuals currently affiliated with a gang and will require a sworn affidavit of non-affiliation.
Are you currently on probation?*

YesNo
If yes, please provide the name and contact information of your probation officer.
Agreement

By signing this form, I represent to the Survivors of Violence Foundation, the information provided is current, complete, and accurate to the best of my knowledge. Additionally, I agree that if I am approved for treatment through the foundation, my information (photos, video, and story) will be listed publicly on the Survivors of Violence website, in publications, on television, and on social media. By signing below, I agree to those terms and the use of my information.
Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

Survivors of Violence Foundation Treatment Application

The foundation will not accept individuals currently affiliated with a gang and will require a sworn affidavit of non-affiliation.

Agreement