Caregiver of Medically Fragile Child
*
First Name
Last Name
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Email
*
Phone
*
(###)
###
####
Are you the primary legal parent or guardian of a medically fragile child?
*
Child's Full Legal Name
*
First Name
Last Name
Child's date of birth
*
MM
DD
YYYY
Primary Care Provider or Specialist overseeing child's care
*
First Name
Last Name
Brief description of child's current condition
What services are you interested in?
*
If requesting help with a specific payment, please upload a copy of: Lease or mortgage statement, Proof of past-due balance or eviction notice (if applicable), Child's medical documentation (diagnosis summary and letter from medical provider overseeing care/social worker of need for assistance related to diagnosis and caregiving responsibilities)
Brief Explanation of financial hardship (e.g., missed work, travel costs, caregiving duties)
*
Type of current housing
*
Are you currently behind on Rent/Mortgage?
*
If yes, how many months behind?
*
Monthly rent or mortgage amount. If not applicable type 0
*
Amount Currently owed in rent/mortgage. If not applicable type 0.
*
Number of people in household:
*
Are you or anyone in the household employed?
*
Any other income received in the household?
*
Gross monthly income
*
What is the urgency timeline of your request?
*
If no specific urgent deadline is set, please choose how soon assistance is needed
*
How did you hear about us?
Doctor or Social Worker
Local Community Resource Agency
Hospital
Local School
Other
Electronic Signature
*
By signing below, I confirm the information provided is accurate to the best of my knowledge. I understand submitting this application does not guarantee assistance and is subject to available funding and eligibility
First Name
Last Name
