Applicant InformationParent/Guardian Name(s) First & Last Name Address City State / Province / Region ZIP / Postal Code PhoneEmail Child InformationChild's Name First & Last Name Date Of Birth MM slash DD slash YYYY DiagnosisDate Of Diagnosis MM slash DD slash YYYY Length Of TreatmentCurrently In Patient or Outpatient? In Patient Out Patient How far away from your home is the hospital where you are receiving treatment?Is your child deceased? Yes No Deceased Date MM slash DD slash YYYY Current Medical Provider:Current Medical Facility:Residency VerificationDo you reside in the United States? Yes No Financial InformationEstimated Monthly Medical ExpensesSources of IncomeTotal Annual Household IncomeOther Significant Financial Challenges (e.g., transportation, housing, utilities)Grant Request InformationAmount Requested (limited to need requesting)Please enter a number greater than or equal to 1.Purpose of Grant (check all that apply) Medical Expenses Family Support Services Transportation to Medical Appointments Specialized Equipment Living Expenses Utility Bills Groceries Other Other (please specify)Please provide a brief explanation of how this grant will be used to support your familyAttach additional page if necessaryMax. file size: 64 MB.Required AttachmentsProof of DiagnosisLetter from a healthcare provider confirming the child’s diagnosis, date of diagnosis, length of treatment, and current treatment status. Drop files here or Select files Max. file size: 64 MB. Financial DocumentationRecent tax returns, pay stubs, or other proof of income. Drop files here or Select files Max. file size: 64 MB. Copies of medical bills or other relevant expenses. Drop files here or Select files Max. file size: 64 MB. Personal StatementA brief explanation of your family’s situation, challenges faced, and why this grant is essential.Acknowledgment and SignatureSignatureBy signing below, I certify that the information provided in this application is accurate and truthful to the best of my knowledge. I understand that incomplete applications may delay the review process and that all grants are subject to approval by the Avalynn’s Hope Foundation Grant Committee.Date MM slash DD slash YYYY Δ
