Patient's Name *

First Name

Last Name

Patient's Birthdate *

MM

DD

YYYY

Patient's Gender *

Male

Female

Other

Race/ethnicity that best describes the patient *

American Indian / Alaska Native

Asian

Black / African American

White - Non-Hispanic

White - Hispanic

Hispanic / Latino

Native Hawaiian / Pacific Islander

Multi-Racial

Middle Eastern / North African

Other

Prefer not to say

Patient's Diagnosis Date *

MM

DD

YYYY

Patient's Social Worker's Name *

First Name

Last Name

Parent/Guardian's Name *

First Name

Last Name

Parent/Guardian's Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Parent/Guardian's Cell Phone *

(###)

###

####

Are you employed? *

Yes

No

Second Parent/Guardian's Address (If Applicable)

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Second Parent/Guardian's Cell Phone (If Applicable)

(###)

###

####

Are you employed?

Yes

No

Do you pay rent or a mortgage? *

Rent

Mortgage

Niether

Assistance Needed from Amanda Hope Rainbow Angels *

Utilities (Please attach a copy of the bill(s) below)

Groceries

Gas

Other

Would you like information for any of our other programs?

Amanda Hope Blog (tools to get you through your journey)

Comfort and Care counseling services

Comfycozy's for Chemo adaptive apparel

Major Distractions free events

Important Notice Acknowledgement *

Amanda Hope Rainbow Angels is a charitable organization dependent upon the public for support. The Amanda Hope Rainbow Angels tries to maximize the limited resources available. These guidelines are a statement of the Amanda Hope Rainbow Angels’ general policy, and Amanda Hope Rainbow Angels reserves the right, in its sole discretion, to modify the same at any time without notice. You will not be discriminated against or denied aid because of your race, religion, color, national origin, sex or political affiliation. All financial applications will be reviewed on a case by case basis and final determination will be made based upon other applications submitted and the availability of funds. The information you provide to us will be held in confidence and used only in appropriate ways consistent with the reasons for which it was provided.

I have read the Important Notice Acknowledgement

Consent to Release Information and Affirmations *

I do hereby authorize all hospitals, financial institutions, and insurance groups to release to Amanda Hope Rainbow Angels, or its duly authorized representative, any information deemed necessary to complete its investigation of my application for financial assistance. In addition, I do hereby authorize all hospitals, financial institutions, and insurance groups to release to Amanda Hope Rainbow Angels, or its duly authorized representative, any information or itemized statements that pertain to bone marrow transplant and related expenses. I further authorize Amanda Hope Rainbow Angel's and its representatives to provide such information to those institutions as may be reasonably required to assist our family and our child. All consents given herein shall continue until such time as the undersigned provides notice of termination in writing. As an inducement to Amanda Hope Rainbow Angels, a non-profit organization, to advance supplemental family support expenses in conjunction with the medical treatment of my child, the undersigned hereby affirm as follows: 1. The undersigned are the parents or guardians of the child. 2. The term “non-medical expenses” is understood to mean those reasonable and necessary expenses incurred by the family or guardian of the above-named child in conjunction with that child receiving medical treatment. Financial assistance will be restricted to the use of said funds to be specified by Amanda Hope Rainbow Angels.

Yes, I consent to release information and affirmations

Guidelines and Information *

I have read the guidelines for financial assistance and I declare that the information furnished on this application form, including attached sheets, is true and correct to the best of my knowledge.

SMS/Email Opt-in

By checking the box, I agree by electronic signature to be contacted about Amanda Hope Rainbow Angels by SMS text at my residential or cellular number or provided email address, dialed manually or by autodialer (consent to be contacted is not a condition to receive services) and to be contacted via email. I consent to be contacted even if my phone number or email address appears on an Amanda Hope Rainbow Angels Do Not Call / Do Not Email List, a State or National Do Not Call Registry, or any other Do Not Contact List.