Hero 4 Life Application Applicant InformationName* First Last Date of Birth* MM slash DD slash YYYY 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 Please consider sending a photograph of your child.Max. file size: 50 MB.Your child's name and date of birth Optional, but we'd love to know.Parent/Guardian InformationName First Last Date of Birth MM slash DD slash YYYY Name First Last Date of Birth MM slash DD slash YYYY Relationship to Patient PhoneEmail 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 ages Assistance 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 Other 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 Employer Is Parent / Guardian on unpaid leave? Yes No Guardian's Employer Is 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 Hospital Social Worker Diagnosis If brain tumor, grade Date of diagnosis MM slash DD slash YYYY Number of relapses Date(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? 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.Required DocumentsDoctor's note with current treatment.Max. file size: 50 MB.Required, but if you're submitting on a phone or don't have ready access, we can follow up with you in email to get this.Most recent tax returns.Max. file size: 50 MB.Required, but if you're submitting on a phone or don't have ready access, we can follow up with you in email to get this.*Please note that applications will not be considered until all documents are received. Thank You. Δ
