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
Home Address:*

Street Name

Street Address Line 2

City / State / ZipState / Province

Postal / Zip Code
Phone:*
Please enter a valid phone number.Format: (000) 000-0000.
Email Address:*
example@example.com
Do You:*
Monthly Mortgage/Rental Payment:*
Employment Information
Current Employer:*
Employer Phone:*
Format: (000) 000-0000.
Position:*
Salary:*
Is this your salary monthly or yearly?*
Other Income Source:
Other Income Source Amount:
Spouse/Significant Other (Living in same residence)
Spouse/Significant Other Name:
First / MI / Last
Date of Birth (Spouse/Significant Other):

MonthDayYear
Date
Spouse/Significant Other Employment Information
Current employer (Spouse/Significant Other):*
Phone (Spouse/Significant Other):
Format: (000) 000-0000.
Position (Spouse/Significant Other):*
Salary (Spouse/Significant Other):*
Is this your salary monthly or yearly?*
Other Income Source (Spouse/Significant Other):
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?
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:
How did you hear about Give Hope Foundation?
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.
Please download the RELEASE OF LIABILITY AUTHORIZATION FOR RELEASE AND USE OF
MEDICAL RECORDS form, here. In order for the application to be considered, the release needs to be signed by the doctor or social worker and submitted with the below or emailed to shanleew@pm.me.
Upload your completed Liability and Media Release form below.

Cancelof
Signature of Applicant*
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)

Spouse/Significant Other Employment Information

Sibling Information

Monthly Expenses

Other Financial Assistance

Financial Impact

Use of Photographic Images