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Section 1: Application Information


Child's Name:


Diagnosis:


Birthday:


Address:


Age:

  Gender:

Main Hospital child is being treated at:


How often are you at the Hospital?:


Names and Ages of siblings:



Section 2: Parent/Guardian Information


Mother's or Primary Guardian's Name:


Phone Number:


Email Address:


Gross Monthly Income:


Father's Name:


Phone Number:


Email Address:


Gross Monthly Income:



Section 3: Household Liabilities/Annual Income Information:


Income

Monthly Income from Profession:


Interest and Securities:


Expenses

Rent/Mortgage:


Credit Card Payments:


Car Payments:


Phone Payments:


Utilities:


Has patient family received assistance from
Pearce Family Foundation before?:


Does patient family receive assistance from
other agencies? If so list the agency:


Who referred you to Angels Around Us?



Section 4: Needs Evaluation


Please prioritize your family's needs by numbering them from 1-4

Housing/Rent/Mortgage:
Transportation Bill:
Electric Bill:
Water Bill:

Additional Items/Needs (please list)


Please upload your last paystub (if applicable) your most needed bills and an image of your child/family:
Select A File To Upload:

Section 5: Parent/Guardian Certification Application for Financial Assistance


I certify that the information given in this application is true and correct as of the date set forth opposite my signature and that any intentional misrepresentation of the information contained in the application will result in the loss of current and future assistance form Angels Around Us and may result in civil liability. The applicant releases Angels Around Us from any and all liability which may arise from the sharing of this information to third-parties. The Pearce Family Foundation reserves the right to run a background check on every applicant.

Parent or Guardian's Name (signature):


Date:


Relationship to Patient:


I understand that checking this box constitutes a legal signature confirming that I acknowledge and warrant the truthfulness of the information provided in this document.

Validation Code from Graphic:





 

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Pearce Family Foundation | 5321 E. Washington St. | Phoenix, AZ 85034 | info@pffarizona.com

Copyright 2018 Pearce Family Foundation - All Rights Reserved