The Little Miracles Grant Application
Financial grant on behalf of The Miracle Miles Foundation, Inc. [approved 501(c)(s) organization; EIN: 39-3875949] for parents/guardians while baby is experiencing a current extended stay in the NICU (more than 90 days) at Winnie Palmer Hospital (Orlando, FL) or Johns Hopkins All Children's (St. Pete, FL), with an expected further continued stay of more than 30 days.
We understand first-hand how challenging a long NICU stay can be for families. The Little Miracles Grant exists to help ease that burden whenever we can, to allow you more time with your baby without the immense stress of making ends meet. Because our program is supported by donations, the number and amount of grants we can provide depend on the funds available at the time of application.
This application should take 5-10 minutes and requires certain attestations and supporting documentation.
Section 1: Applicant and Family Information
Baby Name:
*
First Name
Middle Name
Last Name
Baby Date of Birth:
*
-
Month
-
Day
Year
NICU Residence (choose one):
*
Winnie Palmer Hospital (Orlando, FL)
Johns Hopkins All Children's (St. Pete, FL)
Date of Initial NICU Admission (Your baby's Initial NICU Admission date must be 90 days or more prior to the completion of this application for consideration as our Foundation's funds are limited and reserved for families experiencing extended stays. Thank you for your understanding):
*
-
Month
-
Day
Year
Expected NICU Discharge Date:
*
30-90 days out
90-120 days out
>120 days out
Parent/Guardian Full Name #1 (Primary Contact/Applicant):
*
First Name
Last Name
Parent/Guardian #1 Relationship to Baby:
*
Parent/Guardian Full Name #2:
First Name
Last Name
Parent/Guardian #2 Relationship to Baby:
Primary Contact/Applicant Preferred Email Address:
*
example@example.com
Primary Contact/Applicant Cell Phone Number:
*
Please enter a valid phone number.
Format: (000) 000-0000.
Primary Contact/Applicant Preferred Mailing Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
How many other children, if any, are there in the household (please provide ages)?
*
Assigned Hospital Social Worker Name:
*
First Name
Last Name
Assigned Hospital Social Worker Email Address:
*
example@example.com
Assigned Hospital Social Worker Phone Number:
*
Please enter a valid phone number.
Format: (000) 000-0000.
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Section 2: Eligibility Confirmation
Are you the legal guardian or primary caregiver of the baby?
*
Yes
No
Are you currently experiencing financial hardship related to your baby’s NICU stay ("Yes" is required for grant approval)?
*
Yes
No
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Section 3: Financial Situation & Needs
Brief description of your family's current financial situation:
*
Estimated total annual gross (before taxes) household income of primary caregiver(s) for the current year:
*
<$25,000
$25,001 - $50,000
$50,001 - $75,000
$75,000 - $100,000
$100,001 - $125,000
$125,001 - $150,000
$150,000+
Primary Areas of Financial Strain (check all that apply):
*
Lost income from unpaid leave
Travel expenses to/from hospital
Childcare for siblings
Lodging/meals near NICU
Medical bills or copays
Other (fill in the blank below)
Other (from previous question):
Have you received other financial grants/assistance during your child's NICU stay?
*
Yes
No
If yes, please explain the additional level of assistance you've received/are receiving:
Receiving additional financial assistance is not a disqualification.
How would you use The Little Miracles Grant, if awarded?
*
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Section 4: Support and Verification
Would you be able to provide a letter or note from your NICU social worker confirming your baby’s stay? ("Yes" is required for grant approval)
*
Yes
No
Upload supporting documentation (if available):
*
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- Hospital letter or admission summary, Photo of hospital bracelet / NICU ID band (optional), and/or Social Worker verification form
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Section 4: Consent & Acknowledgements
I certify that the information provided above is true and accurate, and that my baby's Initial NICU Admission date was 90 or more days ago.
*
Yes
I understand that submission does not guarantee receipt of a grant.
*
Yes
I am committed to make every effort to spend as much time as possible with my baby during his/her NICU stay, and this grant will help allow me to remain steadfast in this commitment.
*
Yes
I consent to allow The Little Miracles Grant Committee to contact my NICU social worker for verification.
*
Yes
I consent to the organization’s privacy policy and understand my information will remain confidential.
*
Yes
I consent to allow my baby's first name and picture to be shared across our platforms to help raise awareness for The Little Miracles Grant.
*
Yes
I am open to sharing my story or testimonial to help raise awareness for The Little Miracles Grant.
*
Yes, I would be open to this
No, I would prefer to stay completely anonymous
Please share a picture or two of your Baby!
*
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Signature
*
Please verify that you are human
*
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