Family Relief Grant Application

Section 1 Parent/Guardian Information

Name
Name
First Name
Last Name
Address
City
State/Province
Zip/Postal
Country

Section 2 – Parent/Guardian #2 (IF APPLICABLE)

Section 3 – Income & Employment Information

$
Family Income Sources (check all that apply)

Section 4 – Please List All Household Members Here:

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Section 5.1 – Use of Funds

All approved funds are paid directly to the vendor and usually fall into the categories below.

  • Medical
  • Travel for medical attention
  • Mortgage/Rent
  • Utilities
  • Property Taxes/Homeowner’s insurance
  • Vehicle expenses/Insurance
  • Funeral
$

Section 5.2 – File Uploads (Bills, Invoices, W9)

Please include a copy of the bill(s)/invoice(s) to be funded, as well as a W9 from the vendor where the bill is to be paid.

Maximum file size: 6MB

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Section 6 – Social Worker

This section must be completed by a licensed social worker from the hospital where the patient is receiving care or from a related support organization (e.g., Ronald McDonald House).
Name of Social Worker
Name of Social Worker
First Name
Last Name
Name
Name
First Name
Last Name

Section 7 – Certification

Certification: Before submitting your application, please read the following statement carefully and check the box to confirm your agreement.
Certification
Name
Name
First Name
Last Name
Name
Name
First Name
Last Name
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