Application for AssistanceAngels of Holistic Care Foundation

Application for AssistanceAngels of Holistic Care Foundation
Applicant Information
MyselfMy Child or dependent
Applicant / Patient Full Legal Name*

First NameLast Name
Applicant / Patient Date of Birth*

MonthDayYear
Date
Parent or Guardian Full Name (if applicable)
Relationship to Applicant
Contact Information
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email*
example@example.com
PhoneEmailText
City and State of Residence*
Household & Financial Snapshot
Number of people in household*
Full-TimePart-TimeUnemploymentUnable to work due to health reasons
Under $1,500$1,500–$3,000$3,001–$5,000Over $5,000
Lyme & co-infectionsChronic illnessNutritional supportOther
Please briefly describe your current situation and why assistance is being requested*
Type of Assistance Requested
Initial Consultation (includes Epigenetic Hair Analysis)Follow-up Visit(s)Nutritional SupplementsOther
Financial Need Verification (Required)
To ensure responsible use of charitable funds, applicants must provide at least one form of financial need verification. If documentation is not available, a written statement of financial hardship is acceptable.
Recent pay stubMost recent tax return (first page only; sensitive info may be redacted)Proof of public assistance (SNAP, SSI, SSDI, Medicaid, WIC, etc.)Unemployment or disability documentationWritten statement of financial hardship
Upload Financial Verification*

Cancelof
Acknowledgment & Consent
I understand that submitting this application does not guarantee assistance. Applications are reviewed by authorized leadership in accordance with organizational guidelines and available resources.I certify that the information provided is true and accurate to the best of my knowledge.I consent to Angels of Holistic Care Foundation reviewing this information solely for the purpose of determining eligibility for assistance.If applying on behalf of a child or dependent, I confirm that I am the parent or legal guardian and authorized to submit this application.
Electronic Signature (Type Full Legal Name)*
Date*

MonthDayYear
Date
Should be Empty:

Application for AssistanceAngels of Holistic Care Foundation

Applicant Information

Contact Information

Household & Financial Snapshot

Type of Assistance Requested

Financial Need Verification (Required)

Acknowledgment & Consent