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Please fill out the form below to apply for assistance. NOTE: The more completely you fill out the form the better Hometown Heroes can evaluate your level of need.
Child's Full Name *
Gender Male Female *
Birth Date (mm/dd/yyyy) *
Primary Spoken Language *
Street Address *
City *
State <Select State> AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY *
Zip *
County *
Contact Phone (000) 000-0000 *
Email
Please provide information about your child's diagnosis and describe their life threatening/altering illness or injury
How has your child's illness/injury affected your family financially
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Mother/Guardian 1 Name *
Home Phone
Cell Phone
Same Address As Child
Mailing Address *
Driver's License State
Driver's License Number
Father/Guardian 2 Name
Same Address as Guardian 1
Mailing Address
City
State <Select State> AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY
Zip
I authorize the following person(s) to be contacted and give my permission to turn my child over to this person(s) in case of an emergency and I cannot be reached.
Contact 1 Name
Relationship
Contact 2 Name
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How did you hear about Hometown Heroes? Newspaper Ad Internet Friend Magazine Staff Member Brochure Doctor TV Ad Former Recipient Other
Insurance Company
Insurance Phone
Specialist's Name
Specialist's Phone
Hospital
Pediatrician's Name
Pediatrician's Phone
Address
Does your child use/have any of the following (Check all that apply) wheelchair crutches walker splint braces artificial limb amputation
Other Limitations
Please let us know how your child's recent history has been. Specifically, describe your child's living situation (who he/she lives with), school situation (how he/she interacts socially and in class), recent hospitalizations and any other major adjustments (change of address, birth of sibling, recent losses, etc.).
Does your child have any special needs (emotional) that you need to share with us?
Please describe any specific challenges your child has
How often does your child require physical assistance at home or in school? None of the time Some of the time All the time
If you answered all of the time or some of the time, please give examples (i.e., when changing, physically transitioning, toileting, etc.).
What are your child's major interests?
Please provide any other information that would be benefitial for us to know to provide the best experience possible.
Please list a non-family contact person for additional psychological/social information (teacher, therapist, child life specialist, etc.)
Reference Name
Phone
Upload Child's Photo
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I hereby release, discharge and otherwize indemnify Hometown Heroes, its affiliated organizations and sponsors, its officers, directors, employees, volunteers, and agents against any claim by or on behalf of myself or my minor child as a result of my child's participation in any program or activity sponsored, coordinated, or supervised by Hometown Heroes. I also agree to release, discharge and agree to hold harmless and indemify the parties with respect to any medical expenses resulting from personal injuries sustained by the child while engaged in such activities or otherwise. I also understand that this release includes traveling to or from programs or activities.
I give permission for my child to share addresses and phone numbers with all other children.
I also give Hometown Heroes, sponsors, and authorized news media permission to photograph and to use pictures, video, or audio tapes of my child either alone or in groups for the newsletter, advertising purposes, fund-raising activities, bulletin boards, or in promoting public understanding and support for children with chronic or life-threatening illnesses or substantially similar puposes. Hometown Heroes respects the privacy of the children and their families and does not give permission for unathorized visitors to photograph children.
Submitted By: (please enter your name) *
Submitter's Email *
Enter Security Word
Thank you for submitting your application for assistance. The application will be reviewed and we will contact you as soon as we have made a decision.
User Name
Password
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