Courageous Hearts Financial Assistance Application

Courageous Hearts Financial Assistance Application

Supporting families of critically ill children through direct financial assistance.
Applicant and Child Information
Parent/Guardian Name

First NameMiddle NameLast Name
Relationship to Child
Home Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Child's Full Name
Child's Age
County of Residence
Diagnosis / Critical Illness
Date Diagnosed

MonthDayYear
Date
Treating Hospital or Medical Center
Currently Receiving Treatment?
Medical and Financial Details
Type of Treatment

Other
Describe Your Child's Diagnosis and Current Treatment Plan
Number of People in Household
Annual Household Income
Describe Your Family's Financial Hardship
Type of Assistance Requested

Other
Amount Requested
Please Explain How the Requested Funds Will Be Used
Documents, Authorizations, and Certification
Diagnosis Verification

Cancelof
Fundraising Links
Fundraising Links (optional)
Would you like us to share and promote your fundraiser?
General Media Release
Applicant Certification
Funding Acknowledgement
Electronic Signature
Signature Date

MonthDayYear
Date
Should be Empty:

Fundraising Links