Assistance Application

Assistance Request Application

Hope for Autumn Foundation financially assists families battling childhood cancer who are being treated at Children’s Hospital of Alabama. Requests for assistance are evaluated on a case-by-case basis by the Executive Board of the foundation and are honored based on available funding and other factors. Examples of approved requests in the past have been payment of rent, utilities, or medical expenses, gas cards, travel vouchers, gift cards to grocery stores, and funeral expenses. Please fill out the form as completely as possible, and allow up to two weeks for your request to be processed. If emergency assistance is needed, please email Amanda Knerr, executive director, at amandaknerr@hopeforautumnfoundation.org.

All applications will be reviewed on a case-by-case basis and a final determination will be made based upon other applications submitted to Hope for Autumn Foundation and the availability of funds. You will not be discriminated against based on race, religion, color, national origin, sex, or political affiliation.

Child's Name

First Name

Last Name

Child's Date of Birth

MM

DD

YYYY

Mother's Name

First Name

Last Name

Father's Name

First Name

Last Name

Home Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Is your child a patient at Children's of Alabama?

Yes

No

Has your family received assistance?

Yes

No

Give a brief background of your child’s history with childhood cancer.

Website, CaringBridge, or Facebook page

http://

Email

Phone

(###)

###

####

Amount Requested

$

Describe what the financial assistance will be used for.

I authorize Hope for Autumn Foundation and its agents and representatives to contact Children's of Alabama social workers and medical staff in order to verify my child's diagnosis.

Yes

I authorize Children's of Alabama to release to Hope for Autumn Foundation and its agents and representatives any information and medical records deemed necessary by Hope for Autumn Foundation to complete its verification of my child's diagnosis.

Yes

I attest that the information provided above and accompanying this application is true and correct to the best of my knowledge. I acknowledge that Hope for Autumn Foundation will pursue and is entitled to restitution for a grant if it is determined that the information submitted on this application is false.

Yes

Would you be willing to share your story or part of your story with our generous donors to assist in the fundraising process? No last names will be used.

Yes

No

Assistance Application

Assistance Request Application

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