FINANCIAL ASSISTANCE APPLICATION

FINANCIAL ASSISTANCE APPLICATION
Please provide as much information as possible so we can accurately assess your family's needs. All information submitted is kept strictly confidential.

To complete your application, please upload:

Copies of the first two pages of the prior year’s tax returns for parents/guardians.

A few photos of your child (in treatment and with the family)

These documents are required to process your application and can be attached at the end of this form.

We will review your application as soon as it is received and will follow up with your status and the next steps in the process.
Parent/Guardian Information
Date

MonthDayYear
Date
Name*
D.O.B
Relationship to the Child*
Cellphone number*
Email*
example@example.com
Address*
City*
State*
Zip*
Current Employer
Position
Address
Phone
Income
Parent/Guardian Information
Name
D.O.B
Relationship to the Child
Cellphone number
Email
example@example.com
If you address is the same as the address previously entered - please click the box below.

Same as Above
Address
City
State
Zip
Current Employer
Position
Address
Phone
Income
Parent/Guardian Marital Status
Parent/Guardian Living Arrangement
Child lives with (check all that apply)

MotherFatherGuardianSiblings
Primary Language

EnglishSpanishOther:
Are you a U.S. Citizen?

YesNo
If you are NOT but the child is, please provide child’s documentation or SS number.
Name and DOB of Minor Siblings
Name
D.O.B
Age
Name
D.O.B
Age
Name
D.O.B
Age
Name
D.O.B
Age
I identify my ethnicity as*

African AmericanAsian/Pacific IslanderNative AmericanMixed DescentWhite/CaucasianHispanic/LatinoOther
Child Interest information: (For our Champion Day Program)
Favorite Sport
Favorite Athlete
Favorite Team
Favorite Hobby
Child/Patient Information
Child’s Name*
Age*
D.O.B*
Gender*
Type of Illness*
Relapse

YesNo
Prognosis
Present Treatment*
Date Treatment Began*

MonthDayYear
Date
Anticipated Completion of Treatment
Hospital Name*
Treatment Facility Address
Hospital Telephone*
Doctor’s Name*
Doctor’s Phone*
Social Worker’s Name
Social Worker’s Phone
Do you give permission for your social worker or case manager to release your information to Mitchell Thorp Foundation for review to determine assistance?*

YesNo
Do you have Medical Insurance?

YesNo
If yes, please list your Insurance Company name.
Secondary Insurance
Does your Household receive Federal Health Insurance assistance?

YesNo
Child's Daily Regimen
Child's Alternative Regimen: (i.e. Hyperbaric therapy, vitamins, acupuncture, massage therapist, etc)
Current Combined Family/Guardian Income
Total Household Income
Other Income
Social Security Income
IHSS
Food Stamps
Child Support
Unemployment
Other
Current Family Assets
Checking Institution (Bank Name)
Balance
Savings Institution (Bank Name)
Balance
Other- Describe
Auto 1 (Year/Make)
Value
Auto 1 (Year/Make)
Auto 1 Value
Auto 2 (Year/Make)
Auto 2 Value

Expenses:

	Amount Owed	Mo. Payment	Creditor
Mortgage/Rent
Other Mortgage/Liens
Auto Loan 1
Auto Loan 2
Credit Card
Medical Debts
Health Insurance
Car Insurance
Child Support

If you have received assistance from other organizations, please list them here with dollar amount:
1.
2.
3.
What are your primary assistance needs at this time?
Describe your current support network: Family, Friends, Work, Community, Church, etc.
Will your support network be willing to help with fundraising efforts if needed?

YesMaybeNo
Sometimes families choose to have a fundraising page where friends, family, and community members can contribute. Would you like us to provide you with more information about this option?

YesNo
How did you find out about the Foundation?
We occasionally highlight family stories (always with permission) to help raise awareness and offer hope to others. If your family or child has a public social media presence and you’d be open to us viewing it or potentially connecting in the future for awareness opportunities, feel free to share below. Would you like to share a social media page with us?
Instagram
TikTok
Facebook
Application Agreement: I hereby apply for assistance to meet medical and/or non-medical expenses related to my child’s medical care not covered by my private/public insurance or any other agency and that I cannot otherwise pay without undue hardship. The type and amount of assistance provided will be determined by Mitchell Thorp Foundation. I vouch for the truth and accuracy of all information given in this application. I authorize disclosure of information relevant to my child’s medical condition to Mitchell Thorp Foundation. I also authorize disclosure to Mitchell Thorp Foundation of any information relevant to my application as well as any information from insurance or other pertinent agencies. I have been informed that any falsely submitted documentation or information will automatically disqualify this application and eligibility for any further assistance from this organization.

I understand that Mitchell Thorp Foundation Board of Directors determines the amount they will assist for each family by a case-by-case basis.
Signed: Date

MonthDayYear
Date
Parent/Guardian
Parent/Guardian Signature

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Date

MonthDayYear
Date
If filled out by social worker, please sign and date
Social Worker
Social Worker Signature

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Date

MonthDayYear
Date
PUBLIC RELATIONS RELEASE
Please provide the foundation with a few photos of the child in treatment and with the family, along with the application. Upon receipt of parent approval, The Mitchell Thorp Foundation uses pictures of families and children we have helped in the past. This encourages our donors to keep contributing to our efforts in helping families whose children suffer from a life-threatening illness, disease, or disorders. Authorization for information release is voluntary and does not affect families’ eligibility to receive financial assistance.
Parent/Guardian Authorization
I hereby give my consent to the Mitchell Thorp Foundation to use my child’s story to be told. I release them from any expectation of confidentiality for the undersigned minor children and myself and attest that I am the parent or legal guardian of the children listed. (Please email some photos of child and family to beth@mitchellthorp.org) Photographic and Video Release and Intellectual Property Rights. I grant full permission and rights to use, without compensation, photographic images and videos of me and my children and quotations made by me and my children relating to our service in materials, advertisements, or other promotions for Mitchell Thorp Foundation. I understand that it is the policy of Mitchell Thorp Foundation to use only first-names, pseudonyms, or de-identified images, videos, or quotations in its materials to help protect my privacy and the privacy of my child(ren
Parent/Guardian Print Name
Parent/Guardian Signature

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Date

MonthDayYear
Date
Referral Information
Name
Address
State
State
Zip
Email
example@example.com
Cell phone
Relationship to Child
Attach First 2 Pages of your Tax returns from the previous year. *

Cancelof
Please attach recent photos of your family and/or child.

Cancelof
Name
Should be Empty:

FINANCIAL ASSISTANCE APPLICATION

Parent/Guardian Information

Parent/Guardian Information

Name and DOB of Minor Siblings

Child/Patient Information

Current Combined Family/Guardian Income

Current Family Assets

PUBLIC RELATIONS RELEASE

Parent/Guardian Authorization

Referral Information