Lionheart's Children Foundation Family Support Application
Please complete this application to help us understand your family's needs and how we can best support you. All information is kept confidential.
Parent/Guardian Information
Full Name of Parent/Guardian
*
First Name
Last Name
Relationship to Child
*
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Preferred Language for Communication
*
Please Select
English
Spanish
French
Other
Preferred Contact Method
*
Email
Phone Call
Text Message
Other
Household Information
Number of Adults in Household
*
Number of Children in Household
*
Ages of Children (please list each child’s age)
*
Is a social worker or case manager involved with your family?
*
Yes
No
If yes, please provide their name and contact information
Child’s Medical/Support Needs
Child’s Full Name
*
Child’s Age
*
Medical Conditions or Diagnoses (if any)
Primary Healthcare Provider Name
Healthcare Provider Contact Information
Current Needs or Challenges
*
Is your child currently receiving any support services?
*
Yes
No
If yes, please describe the support services being received
Assistance Requested
What types of support are you seeking from the Unity Project? (Select all that apply)
*
Financial Assistance
Medical Supplies/Equipment
Therapy Services
Educational Support
Transportation Assistance
Respite Care
Other
How can the Unity Project best support your child and family?
*
Required Verification
Are you the child’s legal guardian?
*
Yes
No
Upload proof of identity (e.g., government-issued document)
*
Upload a File
Drag and drop files here
Choose a file
Cancel
of
Upload verification of child’s medical or support needs (e.g., doctor’s letter, evaluation)
*
Upload a File
Drag and drop files here
Choose a file
Cancel
of
Please describe your family’s current situation and reasons for applying
*
Are you currently participating in any assistance programs?
*
Yes
No
If yes, please specify the program(s)
Do you give permission for the Unity Project to contact your child’s healthcare or support providers for additional information, if needed?
*
Yes
No
If yes, please provide provider contact information
Emergency Contact Information
Emergency Contact Name
*
First Name
Last Name
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Relationship to Child
*
Optional Documentation
Upload proof of address (optional)
Upload a File
Drag and drop files here
Choose a file
Cancel
of
Demographic Information
Which of the following best describe your household? (Select all that apply)
Single-parent household
Two-parent household
Grandparent-led household
Foster family
Adoptive family
Other
Privacy Notice
*
By submitting this form, you acknowledge that you have read and understood the privacy notice.
I hereby give my explicit consent for the Unity Project to collect, use, and disclose my personal and health information as described in the privacy notice.
*
I Consent
I Do Not Consent
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