Golden Halo Foundation Funding Application

Golden Halo Foundation Application
Please note - all fields on this form are marked as mandatory. If the field does not apply to your situation, please enter "NA" for not applicable.
Recipient Information
Date

MonthDayYear
Date
Name*

First NameLast Name
Date of Birth*
SSN*
Sex*
Citizenship*

Family Information
Mother's Name*
Phone Number*

Area CodePhone Number
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Occupation*
Father's Name*

First NameLast Name
Phone Number*

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Occupation*
Case Worker's Name

First NameLast Name
Phone Number

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Number in Family*
Primary Caretaker of Recipient*
Type of Insurance Coverage*
Do You Receive SSI or Social Security Disability?*

Clinical Information
Primary Physician*
Phone Number*

Area CodePhone Number
Other Providers*
Clinical Diagnosis*
Age at Onset*
Description/history of Child's Illness or Health Condition*
Description of Request (Travel Expenses, Medications, Etc.)*
How Will This Request Improve the Child's Life?*
Total Amount Requested From Golden Halo Foundation*
Has Funding Been Sought From Additional Sources?*
If Other Funding, From Whom?
Amount of Other Funding

Equipment Request
Please note: receipts and/or invoices for equipment must be attached to this application before it can be considered. Documents can be uploaded at the end of this form.
Type of Equipment*
Cost of Equipment*
Estimated Life of Equipment*
Is Used Equipment and Option?*
Will Provider Participate with Golden Halo Through a Discount?*
If funding is granted, who will receive the payment?
Name*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Current Equipment Recipient Has/Uses*
Any Additional Information Relevant to the Request*

Application Final Checklist
Applications for the Golden Halo Foundation will be considered on a once a month
basis. Applications will be voted on in our monthly board meetings for approval. If at all possible reimbursement for expenses with receipts for medical appointments is requested.

Please complete this checklist to complete the application process for the Golden Halo Foundation.

All of the following items need to be submitted before an application can be considered for funding.
1. Complete Application Form*

Complete all required fields in the Application Form above (indicated with a red asterisk)
2. Files To Upload*

Letters from physician and/or PT, OT or SLP that includes the recommendation for request and benefits of the request for the childOfficial receipts/invoice/estimate on procedure or equipment requested, if a discount is available, and name and address of third party who will receive payment.Letter of denial from insurance or Medicaid, if applicable. If not applicable, please check anyway.HIPAA Authorization Form (you can download this form here here and you will need to sign it then scan in order to upload.)Child's PhotoPhoto Release here here and you will need to sign it then scan in order to upload.)
Upload receipts/invoices/estimates here

Browse Files

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Golden Halo Foundation Photo Release
This release form is to notify you of our intent to publish pictures of your child in various documents relating to Golden Halo Foundation.

We intend to continually highlight Golden Halo recipients in our newsletters,
presentations, website, videos, and special events.

We assume that the photos used in Golden Halo Foundation documents will be viewed by associates and other donors, and not used for any other purposes.

The following is taken from a standard photographic release and grants us your
permission to use photographs of your child in our Golden Halo Foundation documents. Please take a moment to read it and sign below.
Childs Name*
As parent or guardian of the child named below, I hereby grant Golden HaloFoundation the right and permission to copyright and use, re-use and publish, andrepublish the attached photograph of my child, or photographs or pictures inwhich my child is included, in whole or in part, without restriction as to changesor alterations. I also consent to the use of any printed matter in conjunction therewith.I hereby waive any right that I or my child may have to inspect or approve printedmatter that may be used in conjunction therewith or the use to which it may beapplied. I hereby release Golden Halo Foundation and all persons acting upon its authorityfrom any liability by virtue of any blurring, distortion, alteration, optical illusion,or use in composite form, whether intentional or otherwise, that may occur or beproduced in the taking of said picture or in any subsequent processing thereof, aswell as any publication thereof. I hereby warrant that I am of full age and have every right to contract for my child in the above regard. I state further that I have read the above authorization, release and agreement, prior to its execution, and that I am fully familiar with the contents thereof.*

Clear
Parent's Name*

First NameLast Name
Today's Date*

MonthDayYear
Date

I certify that all of the information submitted and the statements that have been made aretrue. I understand that any misrepresentation or omission of facts may result incancellation of my application*

Clear
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Golden Halo Foundation Application

Application Final Checklist

Golden Halo Foundation Photo Release