Hero 4 Life Application Applicant InformationName* First Last Date of Birth* Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code PhoneEmail* Your child's name and date of birth*Please include a short bio and photograph of your child. This will be shared with our donors so they can see and connect with the brave child they are supporting. We believe every story matters, your child's story helps our supporters understand the impact of their generosity.*Photograph of your child.*Max. file size: 50 MB. Parent/Guardian InformationName First Last Date of Birth Name First Last Date of Birth Relationship to PatientPhoneEmail Is address same as patients? Yes No Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Marital Status of Parents / Guardians Married Single Divorced Cohabitants Widowed Separated Who is the custodial guardian of the patient/child?Do guardians speak English? Yes No What is the primary language?Number of children and their agesAssistance RequestedPlease check how you will utilize the assistance. If request is to pay a bill, please include a copy of the bill to be paid. Mortgage Rent Utility Payment Child Care Health Insurance Premiums / COBRA Car Expenses Treatment Related Expenses Other Describe OtherPlease upload copies of any bills to be paid.Please upload copies of any bills to be paid:* Drop files here or Select files Accepted file types: jpg, png, pdf, Max. file size: 50 MB, Max. files: 12. Please describe how this assistance will help your family.Household IncomeTotal annual family incomeFamily income sources (check all that apply): Salary SSI Child Support TANF Other Please explain other.Guardian's EmployerIs Parent / Guardian on unpaid leave? Yes No Guardian's EmployerIs Parent / Guardian on unpaid leave? Yes No How much has family collected in monetary donations?If you have an active donation site please list URL here. Medical InformationReferring HospitalSocial WorkerDiagnosisIf brain tumor, gradeDate of diagnosis Number of relapsesDate(s) of relapse (mm/dd/yyyy)Insurance InformationDoes patient have health insurance? Yes No If yes, please indicate what type of insurance (check all that apply): Private Medicaid Medicaire Other Which type of other?Required DocumentsDOCTOR'S NOTE WITH CURRENT TREATMENT:Doctor's note with current treatment.*Max. file size: 50 MB. MOST RECENT TAX RETURNS:Most recent tax returns.*Max. file size: 50 MB. *Applications will not be considered until all documents are received.Funding ProceduresA member of Team Parker for life will contact you by phone once the application has been received and processed to determine if you have been selected for a grant. Assistance is based on eligibility of funds. You may apply for assistance once per year. To re-apply, you must continue to meet the eligibility guidelines; you must complete a new application for assistance.ProcessingPlease note that processing your application takes time. Every family who applies is incredibly important to us, and because TPFL supports every family who meets our criteria, we carefully review each request. We receive a large volume of requests each month, so we kindly ask for your patience as we work through them. Thank you for allowing us the opportunity to serve your family. Δ
