Child's First Name
Child's Last Name
Child's Date of Birth & Gender
Child's Date of Birth
Please Upload a Photo of Your Child
Please Upload a Photo of Your Child
Please select the child's current caretakers:
Mother's First Name
Mother's Last Name
Mother's Date of Birth
Mother's Date of Birth
Contact Information
+ Mother's Home Phone
Mother's Cell Phone
Mother's Email Address
Address
Mother's Street Address
Mother's Apt, Suite, Unit, Ect
Mother's City
Mother's State
AL
AK
AZ
AR
CA
CO
CT
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Mother's ZIP
Housing
Mother's Housing Situation
Mother's Household Size
CONDITION - Is mother employed?
EM Current Employer
EM Position
EM Business Phone
EM Contact Person
Employer Address
EM Street Address
EM Address Line 2
EM City
EM State
AL
AK
AZ
AR
CA
CO
CT
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
EMZIP
Father's First Name
Father's Last Name
Father's Date of Birth
Father's Date of Birth
Contact Information
+ Father's Home Phone
Father's Cell Phone
Father's Email Address
CONDITION - Do parents live in the same home?
Address
Father's Street Address
Father's Apt, Suite, Unit, Ect
Father's City
Father's State
AL
AK
AZ
AR
CA
CO
CT
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Father's ZIP
Housing
Father's Housing Situation
Father's Household Size
CONDITION - Is father employed?
EF Current Employer
EF Position
EF Business Phone
EF Contact Person
Employer Address
EF Street Address
EF Address Line 2
EF City
EF State
AL
AK
AZ
AR
CA
CO
CT
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
EF ZIP
What is your child's diagnosis?
What is your child's plan of treatment?
Social Worker
What is your child's social worker's name?
Social worker's phone number?
Social worker's email address?
Treating Physician(s)
What is your child's treating physician's name?
Treating physician's specialty?
Physician's phone number?
Physician's email address?
CONDITION - Additional TPs
Additional Physician Details
Treatment
CONDITION - Inpatient care?
What is the name of the hospital where your child is receiving inpatient care?
CONDITION - Is this hospital within 25 miles of your primary residence?
How many miles is the hospital from your primary residence?
What is the estimated length of stay for this hospitalization?
Please describe the type of outpatient care your child is or will be undergoing:
What is the estimated length of time for this treatment?
How often is your child receiving treatment at a hospital facility?
What type of care is administered at home, and how often is it administered?
I was referred to The Do More Foundation by...
Please describe the specific financial need you are seeking help with:
Please provide additional details about the specific financial need you are seeking help with:
Amount you are requesting
CONDITION - Have you received other financial assistance?
Source of other financial assistance:
Amount received
Please explain in detail (include dates assistance was granted and if this assistance is ongoing):
For all files other than "Annual Household Gross Income" - Leave field blank of the amount is "0"
Annual Household Gross Income
Primary job $ (per month)
Alimony $ (per month)
Government Assistance $ (per month)
Child support $ (per month)
Other (provide $ per month and explain)
Please explain how a grant from The Do More Foundation would assist your family
Income Certification
Income Certification Upload
I hereby apply for assistance from The Do More Foundation to assist with expenses related to the chronic illness of my child. I attest that the information contained in this application is true and accurate. I authorize The Do More Foundation to obtain information from our my Doctors or employer to verify the information above that is pertinent to the application and grant request. I understand that any information that is falsely submitted will disqualify me from receiving financial assistance from The Do More Foundation.
First Parent's Signature
First Signature Date
Second Parent's Signature
Second Signature Date
Our grants are made possible by donors who give to help families just like yours. We would like your permission to share your child's first name and diagnosis with our supporters and/or prayer partners, so they have the opportunity to help sponsor your grant. No other personal information is shared.
I authorize The Do More Foundation to use my submitted photograph, if needed, to educate the public about the organization and its services. I understand that our personal information will not be used, only the picture.Photographs will only be used if your family is awarded a grant.
Submit Application
