Abby’ Joy Financial Aide

Grant Application

Please Fill Out The Form Below

As a non-profit organization, Abby’s Joy operates on a limited budget from donations, and we receive many requests for assistance. By completing an application, you enter yourself into our system for consideration by the board before aide can be granted. Unfortunately, we cannot make any promises of assistance, but please do not be discouraged in entering the running as we wish to help in every way that we can!

Parent/Guardian's Name

First Name

Last Name

Child's Name

First Name

Last Name

Child's Birth Date

MM

DD

YYYY

Childs Birth Certificate

We require a copy of your child's birth certificate to verify we are providing assistance to the child's parent or legal guardian. Please email a copy of your child's birth certificate to abbysjoy91119@gmail.com

I agree

Parent Email Address

Social Worker or Case Manager Email Address

Parent Phone Number

(###)

###

####

Parent Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Check Mailed To (if different than above)

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Check Made Out To (if different than guardian)

First Name

Last Name

Child's Website or Care Page

http://

Media Release

I grant permission for Abby's Joy Foundation and its representatives to use photographs of my child or myself, our names and my child’s story to inform families, volunteers, the media and the general public about Abby's Joy Foundation and its programs, services and events. Such materials may be used in, among other items, promotional materials, newsletters or on the internet. If permission is granted above, I, for myself and my child, release all claims against Abby's Joy Foundation and its representatives with respect to copyright ownership and publication, including any claim for compensation related to use of these materials.

I agree

I do not agree

I will email a photograph of my child to abbysjoy91119@gmail.com

Medical Release

I authorize Abby's Joy Foundation and its agents and representatives to contact the medical provider in order to verify my child’s DIPG/ cancer diagnosis. I authorize the above named medical provider to release to Abby's Joy Foundation and its agents and representatives any information and medical records deemed necessary by Abby's Joy Foundation to complete its verification of my child’s DIPG/ Cancer diagnosis. I acknowledge that Abby's Joy Foundation will pursue and is entitled to restitution for a grant if it is determined that the information submitted on this application is false.

I agree