Application Form for Emergency Assistance

Application Form for Emergency Assistance
Applicant Information
Child's Name:*
Date of birth:*

MonthDayYear
Date
Diagnosis
Diagnosis:*
Diagnosis Date:*

MonthDayYear
Date
Doctor:*
Treatment Facility:*
Parent/Guardian Information
Type of Treatment:*
Parent/Guardian Name:*
First / MI / Last
Date of Birth:*

MonthDayYear
Date
Place of birth:*
Home Address:*

Street Name

Street Address Line 2

City / State / ZipState / Province

Postal / Zip Code
Home Phone:*
Please enter a valid phone number.
Email Address:*
example@example.com
How Long?*
Do You:*
Monthly Mortgage/Rental Payment:*
Mortgage/Landlord Name:*
Mortgage Account No.:*
Employment Information
Current employer:*
Employer address:*
City:*
State / Zip:*
How long?*
Type of business:*
Phone:*
Fax:
Position:*
Salary:*
Is this your salary monthly or yearly?*
Supervisors Name:*
Other Income Source:
Amount:
Spouse/Significant Other (Living in same residence)
Spouse/Significant Other Name:
First / MI / Last
Date of Birth:

MonthDayYear
Date
Place of birth:
Employment Information
Current employer:*
Employer address:*
City:*
State/Zip:*
How Long?*
Phone:
Fax:
Type of Business:*
Position:*
Salary:*
Is this your salary monthly or yearly?*
Supervisors Name:*
Other Income Source:
Amount:
Sibling Information
Sibling 1 Name
Sibling 1 Age
Sibling 2 Name
Sibling 2 Age
Sibling 3 Name
Sibling 3 Age
Monthly Expenses
Utilities (Electric, Gas Water):*
Auto Expense (Gas, Repairs, Insurance):*
Phone:*
Medical:*
Medications:*
Dental:*
Eye:*
Insurance:*
Food:*
Clothing:*
Credit Cards:*
Child Care/Elder Care:*
Other:*
Other Financial Assistance
Has money been raised on behalf of the client? Yes/No*
If yes, How Much and How?
Has there been assistance from other organizations? Yes/No*
If yes, Organization name:
Type of assistance:
I authorize Give Hope to share this application with other charitable organizations that may also be able to provide assistance.*
Financial Assistance Requested: (Please Prioritize)*
Financial Impact
What impact has this diagnosis had on your current income or financial situation?*
What other financial resources do you have access to or are you aware of that may assist you with treatment or other related costs?*
Explanation of Emergency Situation:
Use of Photographic Images
The Give Hope Foundation has authorization to use photographic images of the applicant.*
If yes, please download the following Liability and Media Release form, here. Then upload your form below.
Upload your completed Liability and Media Release form below.

Cancelof
Signature of Applicant*

Clear
Date*

MonthDayYear
Date
Should be Empty:

Application Form for Emergency Assistance

Applicant Information

Diagnosis

Parent/Guardian Information

Employment Information

Spouse/Significant Other (Living in same residence)

Employment Information

Sibling Information

Monthly Expenses

Other Financial Assistance

Financial Impact

Use of Photographic Images