Todays Date: *
Mother & Fathers Name: *
Childs Name & Date of Birth: *
Street Address: *
City, State, Zip: *
Own or rent?: *
Fathers Date of Birth: *
Phone Number for Parents *
Mothers Date of Birth: *
EMAIL - REQUIRED FOR CONTACT: *
Marital Status *
If divorced or not married, are you receiving child support?: *
Child's Date of Birth: *
Date Child first became ill:
Is any member of your family not a US Citizen? *
Is your Child a US citizen? *
Mortgage or rent amount: *
Total Number in Household (immediate family only) : *
Total Annual Household Income: *
Is your child or family currently receiving Medicaid benfits?: *
If Yes, do they include meals, travel, hotel, or other assistance besides medical treatment?: *
List ALL expected and current assistance your family is receiving. (Name of Charity or group, and amount. Private charities, Church Group, Hospital, WC, Food stamps, CCMS, Medically Dependent Children Program, Ronald McDonald House, Etc. ) *
Have you had a recent decrease in income or increase in expense due to illness? (explain): *
Specific Need - The more information you provide, the better we can help (Travel Expenses, Utility Bills, Mortgage, Medicine, Food, Hotel, etc.): *
Amount Requested:
If assistance is a check, Make Check Payable to:: *
Address to Send Assistance to: *
Account Numbers to Include on Check (E.G. for utlity/mortgage payment) Copies of your bills to be paid need to be provided with application or soon after to be considered.:
Hospital Name and Location (address if available) : *
Unit in Hospital (NICU, PICU, Floor # Etc.) : *
Illness and Reason for Hospitalization: *
Projected Length of Hospital Stay or Treatment: *
Social Workers Name: *
Social Workers contact information: *
Dr.s Name: *
Hospital/Dr.s Phone Number: *
By
Submitting this application for assistance electronically, you agree to
allow your Doctors, hospital staff, and/or social workers to communicate
with a representative from Bella's Blessing, in person, over the phone,
or via email, to help us determine if your family qualifies for
assistance. All information shared with Bella's Blessing will be kept
confidential. You also certify that all information you provided is
correct at the time of application. Applicants who intentionally leave
out any information of falsify their application will not be eligible
for assistance at the time of discovery or in the future. If any of this
information changes, it is your responsibility to update your
application in a timely manner. Please type your full Legal name in the box.: *
Security Code: *For BFF Use Only: Date Reviewed:
