Submit Application for Assistance Online
In order to apply online for assistance, please complete the application form below.
To fill the form electronically, please download it and open it in Adobe Reader on a computer running either Windows or Mac OS X. The form will display blue boxes corresponding to every question; responses to each question can be entered in the corresponding blue box. When the form is complete, please save it and gather documents for all supplementary materials including:
- A letter of support from one of your child’s therapy or medical providers
- A letter about your child and why he/she needs this grant
- A letter from your insurance company stating that the treatment is not covered by your insurance plan
- Income documentation including: last year’s tax return, check stub from each parent/partner, copy of mortgage/rent, electric, gas, cable, phone bill, etc.
- Any additional relevant information documentation.
Please keep a copy of the application form and supporting documents for your reference. It is important to provide as much information as possible about your request so that your application can be processed without delay. Your application will be treated in confidence and will usually be considered within four weeks.
When you are ready to submit a completed application, please complete the following form. Application content should be in PDF format (maximum total application size is 25 mb). If you need to submit additional documentation or are unable to use the form, please submit information to email@example.com.
[contact-form-7 id=”1783″ title=”Submit Application for Assistance”]