Ishan Gala Foundation financial Assistance Request

Have you completed the IGF initial registration form AND received an acceptance email from Ishan Gala Foundation?Please note-We will NOT review any financial request submitted if you have not completed the initial application and been accepted by IGF. The application can be found HERE

Yes

Parents Name* This field is required.

First Name

Last Name

Child Name* This field is required.Name of Diagnosed Child

First Name

Last Name

example@example.com

Phone Number

Please enter a valid phone number.

Are you or your spouse currently employed?* This field is required.

YESNO

Monthly Income* This field is required.

Please provide us updates about where you are in treatment and any other details they relate to this request

What are you requesting assistance with?

Grocery Gift Card

Gas Gift Card

Rent

Mortgage

Car Payment

Car Insurance

Car Repairs

Utility Bill

Travel Assistance

Clothing

Household Appliance or Furniture

Child/infant Transportation Equipment, etc (strollers, car seat, wagons, highchairs)

Meal Assistance (inpatient or at home during major surgeries or medical events)

Medical Bill

What is the amount you are requesting for this bill?* This field is required.

Please upload a copy or image of the bill

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

Payment informationIf approved, payment will be made directly to company or landlord with the exception of gift cards, which will be sent electronically unless physical is requested.

Name of payee

Account Number

Website or link to make payment

Mailing address for payment if payment can't be made online

Do you have another request?

YESNO

What are you requesting assistance with?

Grocery Gift Card

Gas Gift Card

Rent

Mortgage

Car Payment

Car Insurance

Car Repairs

Utility Bill

Travel Assistance

Clothing

Household Appliance or Furniture

Child/infant Transportation Equipment, etc (strollers, car seat, wagons, highchairs)

Meal Assistance (inpatient or at home during major surgeries or medical events)

Medical Bill

What is the amount you are requesting for this bill?* This field is required.

Please upload a copy or image of the bill

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

Payment informationIf approved, payment will be made directly to company or landlord with the exception of gift cards, which will be sent electronically unless physical is requested.

Name of payee

Account Number

Website or link to make payment

Mailing address for payment if payment can't be made online

Do you have another request?

YESNO

What are you requesting assistance with?

Grocery Gift Card

Gas Gift Card

Rent

Mortgage

Car Payment

Car Insurance

Car Repairs

Utility Bill

Travel Assistance

Clothing

Household Appliance or Furniture

Child/infant Transportation Equipment, etc (strollers, car seat, wagons, highchairs)

Meal Assistance (inpatient or at home during major surgeries or medical events)

Medical Bill

What is the amount you are requesting for this bill?* This field is required.

Please upload a copy or image of the bill

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

Payment informationIf approved, payment will be made directly to company or landlord with the exception of gift cards, which will be sent electronically unless physical is requested.

Name of payee

Account Number

Website or link to make payment

Mailing address for payment if payment can't be made online

Do you have another request?

YESNO

What are you requesting assistance with?

Grocery Gift Card

Gas Gift Card

Rent

Mortgage

Car Payment

Car Insurance

Car Repairs

Utility Bill

Travel Assistance

Clothing

Household Appliance or Furniture

Child/infant Transportation Equipment, etc (strollers, car seat, wagons, highchairs)

Meal Assistance (inpatient or at home during major surgeries or medical events)

Medical Bill

What is the amount you are requesting for this bill?* This field is required.

Please upload a copy or image of the bill

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

Payment informationIf approved, payment will be made directly to company or landlord with the exception of gift cards, which will be sent electronically unless physical is requested.

Name of payee

Account Number

Website or link to make payment

Mailing address for payment if payment can't be made online

Name

First Name

Last Name

example@example.com

Phone Number

Please enter a valid phone number.

Relationship to Family

Social Worker

Family member

Friend of family

Other

Ishan Gala Foundation financial Assistance Request