Assistance Request Form (Old)

 

    Dear Family,

    Angel’s Hands Foundation enjoys being part of the community by offering assistance to
    families living with rare diseases. The support we offer to families is intended to improve the
    quality of life for their sick family member, thereby improving the lives of the entire family.
    Angel’s Hands Foundation offers assistance for medical services and equipment, social
    activities for socialization and emotions support to families, educational opportunities, and
    support of national organizations in ways that directly impact the quality of lives for Utah
    families.

    If you request assistance from Angel’s Hands Foundation for your family or organization
    please fill out the enclosed forms. The amount of assistance awarded will be based on the
    review of the application by Angel’s Hands Foundation Board of Directors. Please give some
    thought to the amount of assistance you need, above what you are capable of paying yourself.
    Angel’s Hands Foundation goal is to help as many families as funds allow.
    Application Process and Guidelines for Assistance
    from Angel’s Hands Foundation

    1. Fill out Angel’s Hands Foundation Registration Form.
    2. Fill out Angel’s Hands Foundation Assistance Request Form (at the bottom of this page).
    3. Angel’s Hands Foundation Board will make recommendation and you will be notified.
    4. All applications for assistance must be made in writing. With support documentation on
    necessity of request and benefit for family.
    5. All requests will be processed as soon as possible.
    6. Assistance may cover a portion of the request or it’s entirety as determined by the
    Angel’s Hands Foundation Board of Directors.
    7. Hands Foundation may ask for additional information as they deem necessary.

    AHF may not be able to fully fund all requests for assistance. To see that AHF funds assist as
    many families as possible, we are asking you to fill out the following information to help us
    make the best possible decisions. Additional information may be requested by AHF. All
    information will be kept confidential.

    Assistance Request Recipient

    Name:
    Relationship: Age:
    Primary Diagnosis, disability or condition:
    Parent or legal guardian or applicant (If over 18):
    Address:
    Telephone: Mobile:
    E-Mail Address:
    Your Age: Occupation:
    Married/Single: Number of children:
    Is your spouse working? Occupation:
    Family income for the last 12 months:
    Medical expenses not covered by insurance the past 12 months:
    Insurance carriers:
    Additional financial burdens:
    Are you able to contribute partially to the total cost of your request without causing financial hardship? If yes, amount: