Funding for Families Application

Funding for Families Application

Please list names on application as they are on legal ID: Driver’s License, State ID, Passport, or Birth Certiﬁcate.
Please Note: Wishing to focus on serving our local community well, effective 1/1/2023, Project 4031 will only be accepting applications from people living or receiving hospice or medical care in the following North Texas counties: Collin, Cooke, Dallas, Denton, Ellis, Erath, Fannin, Grayson, Hood, Hunt, Johnson, Kaufman, Montague, Navarro, Palo Pinto, Parker, Rockwall, Somervell, Tarrant, and Wise. Current copies of bills and proof of income are required as part of the application process. Clear copies of the entire bill/statement, showing an up-to-date amount owed, must be visible to be accepted.
Patient Name*

First NameLast Name
Is the patient currently on hospice service?*

YesNo
Treating Physician's Name*

First NameLast Name
Treatment Facility/Hospital Name*
Treating Physician's Phone Number*

Area CodePhone Number
Treating Physician's Email Address*

Confirmation Email
Hospice Representative's Name*

First NameLast Name
Hospice Representative's Title*
Hospice Company Name *
Hospice Representative's Phone Number*

Area CodePhone Number
Hospice Representative's Email*

Confirmation Email
Did this person refer you to Project 4031?*

YesNo
Name of the person who is referring patient for services*

First NameLast Name
Title of person who is referring patient*
Email Address of person who is referring patient*

Confirmation Email
Phone Number of person who is referring patient*

Area CodePhone Number
How did you hear about Project 4031?*

Medical ProfessionalHospice RepresentativeFriend/Family MemberProject 4031 WebsiteProject 4031 StaffWebsite / Social MediaOther
Friend / Family Member's Name*

First NameLast Name
Relationship to Patient*
Friend / Family Member's Primary Phone*

Area CodePhone Number
Friend / Family Member's Email*

Confirmation Email
Address of Patient*

Street Address

Street Address Line 2

CityState

Zip CodeCountry
Primary Phone Number*

Area CodePhone Number
Secondary Phone Number*

Area CodePhone Number
Age*
Date of Birth*

MonthDayYear
Date
Sex*

MaleFemale
Ethnicity*
Religious Preference*
Would you like to be added to our prayer list?

YesNo
Military Veteran*

YesNo
Please Describe Branch and Dates of Service*
Primary Language*

EnglishSpanishOther
Can You Provide Information for a Translator?*

YesNo
Name of Translator*

First NameLast Name
Relationship of Translator to Patient*
Phone Number of Translator*

Area CodePhone Number
Name of Relative or Primary Caregiver*

First NameLast Name
Relationship to patient*
Phone Number of Relative or Primary Caregiver*

Area CodePhone Number
Does the Relative or Primary Caregiver live with the patient?*

YesNo
Address of Relative or Primary Caregiver*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Email Address of Relative or Primary Caregiver*
example@example.com
Has the patient received services from Project 4031 before (Funding for Families or Fulfilling Dreams)?*

YesNo
Please describe the request and date it was granted.*
Has the patient received services from another organization?*

YesNo
Name of organization*
Please describe the service provided and date it was granted.*
Is an application submitted/pending with any other assistance organization?*

YesNo
Name of organization*
Please describe the request.*
Has the patient ever applied and been turned down by another organization?*

YesNo
Name of organization*
Please describe the reason for denial.*
What financial needs is the patient applying for assistance with? Please provide details for each current bill submitted for assistance.*
Please Note: If financial assistance is requested within the 'Food' or 'Other' category, please complete the applicable fields and upload a document with any and all relevant details about the request.”
Please upload copies of each bill listed above.

Browse Files

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If possible, how much is the patient/family able to contribute to the cost of bills submitted?*
Please provide a narrative about current financial hardships and why funding assistance is needed at this time.*
In addition to explaining why funding assistance is needed now, please include details of how the patient/family plans to move forward with some ﬁnancial stability in future months.
Household Information
Please Note: You must select “ADD” to complete the field below. In cases where a patient lives alone, input their information or N/A in the fields and select “ADD” to move forward.
List all people currently living in the household with the patient.*
Does anyone in the household work?*

YesNo
If yes, please list the name of the individual, employer, and income per month. (Please Note: You must select “ADD” to complete this field)*
Does the Patient/Family receive any of the following support?*

The Patient/Family does not receive any support.Social SecurityCompany Pension/RetirementHousingTANFSNAP/Food StampsWICChild SupportOther

What is the household's TOTAL current monthly income?
Proof of Income

Browse Files
Please upload proof of all household income. Pay stubs, letters from employers, social security award letters and bank statements are all acceptable forms of proof. Cancelof
Is the patient covered by any state/federal program or insurance policy?*

No coverageMedicareMedicaidCHIPCSHCNOther
Is the patient under 18?*

YesNo
As the Patient/Authorized Caregiver, I hereby certify that the information contained in this application is true and accurate. If financial assistance has been requested with bills, I understand that current copies of all bills are required to be submitted as part of a complete application.
As the Parent/Authorized Caregiver/Legal Guardian, I hereby certify that the information contained in this application is true and accurate. If financial assistance has been requested with bills, I understand that current copies of all bills are required to be submitted as part of a complete application.

	Monthly Amount
Social Security
Company Pension/Retirement
Housing
TANF
SNAP/Food Stamps
WIC
Child Support
Other

Medical Release
To provide Funding assistance, we will be in contact with your treating physician to obtain information regarding your medical condition and receive a signed Medical Authorization which will enable us to serve you to the best of our abilities. Your application will remain pending until we receive the signed Medical Authorization and supporting documentation.
Physician's Name*

First NameLast Name
Hospital/Treatment Facility Name*
Physician's Phone Number*

Area CodePhone Number
Physician's Email*

Confirmation Email
To provide Funding assistance, we will be in contact with your assigned Hospice Representative to obtain information regarding your medical condition and receive a signed Medical Authorization which will enable us to serve you to the best of our abilities.
Hospice Representative's Name*

First NameLast Name
Hospice Company Name*
Hospice Representative's Phone Number*

Area CodePhone Number
Hospice Representative's Email*

Confirmation Email
As the Patient/Authorized Caregiver, I hereby authorize my Hospice Representative to provide Project 4031 the information necessary to obtain Funding assistance.
As the Patient/Authorized Caregiver, I hereby authorize my treating Physician to provide Project 4031 the information necessary to obtain Funding assistance.
As the Parent/Authorized Caregiver/Legal Guardian, I hereby authorize the patient’s Hospice Representative to provide Project 4031 the information necessary to obtain Funding assistance. I certify that I am the authorized caregiver, natural parent, or legal guardian of the patient with the authority to execute this release permitting Project 4031 to obtain information requested in this application.
As the Parent/Authorized Caregiver/Legal Guardian, I hereby authorize the patient’s treating Physician to provide Project 4031 the information necessary to obtain Funding assistance. I certify that I am the authorized caregiver, natural parent, or legal guardian of the patient with the authority to execute this release permitting Project 4031 to obtain information requested in this application.

HIPAA Privacy Authorization
TO:
Hospice Representative / Medical Professional*

First NameLast Name
Hospice / Hospital / Treatment Facility Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
RE:
Patient Name*

First NameLast Name
Patient's Date of Birth*

MonthDayYear
Date
I understand that information used or disclosed pursuant to this authorization may be disclosed by the recipient and may no longer be protected by federal or state law. I authorize the use and disclosure to Project 4031 of all protected health information about the patient as described below:

Information that may be used/disclosed: I authorize the release of my complete health records including but not limited to information regarding billing, condition, treatment and prognosis, as needed and or requested by Project 4031 in assessing:

A. Whether the patient is medically eligible for Project 4031’s services.

B. If applying for a Dream, whether his/her request is medically appropriate. In addition, the Hospice Representative/Medical Professional is authorized to ﬁll out, sign and provide forms to Project 4031 that may be required relating to medical eligibility, the requested services/Dream and medical considerations.

Persons authorized to use/disclose the information: The Hospice Representative/Medical Professional, as well as his/her authorized representatives.

Persons authorized to receive this information: Employees or other authorized representatives of: Project 4031 – 708 May St, Fort Worth, TX 76104, P 817.653.8976, F 817.841.8250, https://project4031.org Purpose for which information will be used/disclosed: To enable Project 4031 to obtain:

A. Assessments regarding whether the patient is medically eligible to receive services/have a Dream granted by Project 4031 and, if so, whether the requested services/Dream is medically appropriate;

B. And relevant information relating thereto.

Effective time period: This authorization expires once the patient has received services/Dream has been granted by Project 4031 or a determination has been made that the patient is not eligible for services.

Right to revoke: I understand that I can withdraw my permission at any time by giving written notice stating my intent to revoke this authorization to the person/entity named above.

I have read this form and agree to the uses and disclosures of the information as described. I understand that if the person/entity that receives the information described above is not a healthcare provider/health plan covered by federal privacy regulations, such information will no longer be protected by these regulations and could potentially be re-disclosed by the recipient.

Media Release
The stories of the terminally ill children and adults we serve as told to the public allow us to raise funds in efforts to continue our mission. Sharing stories of those we have impacted during their darkest hours is vital as it allows us to continue our work strengthening end of life journeys for more people. We ask your permission to share with the media through print, video, television, radio, digital, internet, and social media, without limitation. Please indicate below with your signature if you do or do not give your permission for Project 4031 to share your story with the general public. The patient’s full name will never be disclosed.
I, hereby GIVE my permission for Project 4031 to share stories and photographs in all of Project 4031’s promotional materials.I, hereby DO NOT GIVE my permission for Project 4031 to share stories and photographs in all of Project 4031’s promotional materials.

Waiver and Release of Liability
The below signed Participant enters into this Waiver and Release of Liability (the “Release”) as of the date set forth below. Pursuant to the terms set forth herein, and as consideration for the right to participate in the Activity (as defined below), I hereby, for myself, my heirs, executors, administrators, assigns, or personal representatives, knowingly and voluntarily enter into this Release and hereby waive any and all rights, claims or causes of action of any kind whatsoever arising out of my participation in the Activity, and do hereby release and forever discharge Project 4031 (a Texas Nonprofit Corporation with its principal place of business in Fort Worth, Texas) and its affiliates, managers, members, directors, employees, agents, attorneys, staff, volunteers, representatives, predecessors, successors and assigns (collectively “Project 4031”), for any claim related to the Activity, including but not limited to illness, paralysis, death, damages, economical or emotional loss, that I may suffer as a direct result of my participation in the aforementioned Activity, including traveling to and from an event related to this Activity.

I acknowledge that this Activity may involve a test of a person's physical and mental limits and may carry with it the potential for death, serious injury, and property loss. The risks may include, but are not limited to, those caused by terrain, location, facilities, temperature, weather, lack of hydration, condition of participants, equipment, vehicular traffic, travel and actions of others.

I am voluntarily participating in the aforementioned Activity and I am participating in the Activity entirely at my own risk. I am aware of the risks associated with participating in this Activity, which may include, but are not limited to, physical or psychological injury, pain, suffering, illness, disfigurement, temporary or permanent disability (including paralysis), economic or emotional loss, and death. These risks and dangers may be caused by my own actions or inactions, the actions or inactions of others at the Resort, and/or the Negligence of the Project 4031; (d) there may be other Risks Not Known to me or that are not readily foreseeable at this time; (e) The social and economic losses and/or damages that could result from the risk(s) COULD BE SEVERE AND COULD PERMANENTLY CHANGE THE FUTURE. Nonetheless, I, for myself and on behalf of my heirs, HEREBY ACKNOWLEDGE, ACCEPT AND ASSUME ALL SUCH RISKS, KNOWN AND UNKNOWN, AND ASSUME ALL RESPONSIBILITY FOR THE LOSSES, COSTS AND/OR DAMAGES FOLLOWING SUCH INJURY, DISABILITY, PARALYSIS OR DEATH, EVEN IF CAUSED IN WHOLE OR IN PART, BY THE NEGLIGENCE OF Project 4031.

In the event that I should require medical care or treatment, I agree to be financially responsible for any costs incurred as a result of such treatment. I am aware and understand that I should carry my own health insurance.

I will, at all times while involved in the Activity, comply with (i) all local, state and federal laws (collectively, the “Laws”) and (ii) any rules and regulations imposed by Project 4031 (collectively, the “Rules”).

I acknowledge that Project 4031 and their directors, officers, volunteers, employees, representatives and agents are not responsible for errors, omissions, acts or failures to act of any party or entity conducting a specific event or activity on behalf of Project 4031.

In the event that claims are made against Project 4031 as a result of my actions or the actions of others accompanying me to the Activity, I acknowledge and agree to be held liable for any and all costs associated with any claims. In the event a claim is made against Project 4031 arising out of the intentional, negligent or reckless acts, I agree to indemnify, defend (with counsel of Project 4031’s choice) and hold Project 4031 harmless from any and all claims, suits, liabilities, damages, losses, costs, fines and expenses whatsoever including but not limited to reasonable attorneys’ fees, whether the claims arise as a result of property damage, personal injury, wrongful death or otherwise. I further agree to indemnify, defend, and hold harmless Project 4031 against any and all claims, suits, liabilities, damages, losses, costs, fines and expenses whatsoever including but not limited to reasonable attorneys’ fees, whether the claims arise as a result of property damage, personal injury, wrongful death or otherwise brought by me or anyone on my behalf, including attorney's fees and any related costs. I further agree to indemnify, defend, and hold harmless Project 4031 from my failure, whether intentional or negligent, to adhere to and comply with the Laws or the Rules and any claims, demands, damages and the like, including attorneys’ fees, that may arise from such failure. My attempt to comply with any Laws or Rules shall not limit my commitments in this Paragraph. I understand that my obligations under this Paragraph shall survive the expiration or termination of this Release.

I understand that this Release is material and necessary to participate in the Activity and I acknowledge that I would not be granted the opportunity to participate in the activity absent the execution of this Release.

I acknowledge that I have carefully read this Release and fully understand that it is a release of liability. I understand that I have been granted the opportunity to have an attorney review this Release, and I have either had an attorney review this Release or consciously made the decision to move forward with the execution of this Release without consulting an attorney. I understand that in executing this Release I am expressly agreeing to release and discharge Project 4031 from any and all claims or causes of action related to the Activity, and I agree to voluntarily give up or waive any right that I otherwise have to bring a legal action against Project 4031 relating to the Activity.

This Release was entered into at arm's-length, without duress or coercion, and is to be interpreted as a release between two parties of equal bargaining strength. Accordingly, the normal rule of construction to the effect that any ambiguities are to be resolved against the drafting party shall not be employed in the interpretation of this Release. Both the Participant and Project 4031 agree that this Release is clear and unambiguous as to its terms, and that no promises not contained herein have been made to induce Participant to enter into this Release. This Release contains the entire understanding between the parties with respect to the subject matter hereof. This Release may not be amended or modified except by written instrument executed by the parties.

This Release shall be governed and construed in accordance with the laws of the State of Texas without regard to the conflict of law provisions. I agree that the federal and state courts in TARRANT COUNTY, TEXAS have exclusive jurisdiction over any dispute that arises from this Release.

In the event that any provision contained within this Release of Liability shall be deemed to be severable or invalid, or if any term, condition, phrase or portion of this Release shall be determined, by a court of competent jurisdiction, to be unlawful or otherwise unenforceable, the remainder of this Release shall remain in full force and effect, so long as the clause severed does not affect the intent of the parties. If a court should find that any provision of this Release to be invalid or unenforceable, but that by limiting said provision it would become valid and enforceable, then said provision shall be deemed to be written, construed and enforced as so limited.
In the event of an emergency, please contact the following person(s) in the order presented:
Emergency Contact 1*

First NameLast Name
Emergency Contact 1*

Area CodePhone Number
Emergency Contact 2

First NameLast Name
Emergency Contact 2

Area CodePhone Number
The "ACTIVITY" shall mean:*
Provide a description of the funding request.
I, the Patient/Authorized caregiver, affirm that I am of the age of 18 years or older, and that I am freely signing this Release. I certify that I have read this Release, that I fully understand its content and UNDERSTAND THAT BY SIGNING IT I GIVE UP SUBSTANTIAL RIGHTS I WOULD OTHERWISE HAVE TO RECOVER DAMAGES FOR LOSSES OCCASIONED BY THE RELEASEES FAULT, AND SIGN IT VOLUNTARILY AND WITHOUT INDUCEMENT.

I am aware that this is a release of liability and a contract and that I am signing it of my own free will.
I hereby certify that I am the Parent/Authorized Caregiver/Legal Guardian of the patient named in this application and do hereby give my consent for the Participant to participate in the Activity, without reservation to the foregoing on behalf of this individual. I affirm that I am of the age of 18 years or older, and that I am freely signing this Release. I certify that I have read this Release, that I fully understand its content and UNDERSTAND THAT BY SIGNING IT THE PARTICIPANT GIVES UP SUBSTANTIAL RIGHTS HE/SHE WOULD OTHERWISE HAVE TO RECOVER DAMAGES FOR LOSSES OCCASIONED BY THE RELEASEES FAULT, AND SIGN IT VOLUNTARILY AND WITHOUT INDUCEMENT.

By signing this electronic document, I hereby certify all information contained in this application is true and accurate. I understand that providing incomplete, misleading, or false information may result in either delay or denial of services.
Signature of Patient/Authorized Caregiver/Parent/Legal Guardian*
Name of Signer*

First NameLast Name
Date*

MonthDayYear
Date
Should be Empty:

Funding for Families Application

Medical Release

HIPAA Privacy Authorization

Media Release

Waiver and Release of Liability