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Application Portal Temporarily Closed

Due to high demand and limited funding, we are not accepting new applications at this time. This is a temporary pause — please check back soon for updates.

Initial Application for Financial Assistance

This shorter application collects what we need for an initial review. Additional documentation may be requested if your application moves forward. Required fields are marked with *.

  1. 1. Child
  2. 2. Medical
  3. 3. Assistance
  4. 4. Parents
  5. 5. Financial
  6. 6. Impact
  7. 7. Consent

1 Child Information
Gender
2 Medical Situation
Is the child currently: *
Is the hospital more than 25 miles from your primary residence? *
3 Type of Assistance Requested
What type of help are you requesting? Select all that apply. *
4 Parent / Guardian Information
Who are the adults legally responsible for the child? Select all that apply. *

Select at least one. The matching section will appear below.

5 Financial Snapshot
Has your household income changed because of the child's medical situation?
Has your family received or applied for other financial help for this need?
6 Final Explanation
7 Confirmation and Consent

Application Requirements

  1. Please complete all areas on the application. Fields not required are marked as optional.
  2. Make sure you have included the name and phone number of the Physician and Social Worker.
  3. Please submit a current picture of the child with the application and history form filled out.

Frequently Asked Questions

No. We are not a diagnosis specific organization so we can help children facing anything from cancer to an illness brought on by an accident.

The grants vary from person-to-person based on a variety of factors, including how much grant money is available for distribution.

Yes. We understand that a child’s medical needs often continue creating other financial needs. We welcome a family to apply more than once for a grant.

 Yes. Sometimes we are able to work directly with a company to pay an outstanding bill on your behalf.