Medical Grant Eligibility Assessment

Referred by:

Child's Information (for whom you are applying):

Click the plus sign at the right of the line below to add additional children, if needed.*

Name	Age	Date of Birth	Sex (M or F)

Does Child have medical insurance?*

Yes
No

If yes, Insurance Name:

Does Child have dental insurance?*

Yes
No

If yes, Insurance Name:

Parent(s)/Legal Guardian(s) Household Information:

Name*

First Last

Address*

Street Address Address Line 2 City State ZIP

Email*

Preferred Phone Numer*

This number is:

Marital Status*

Total Number of Children in household*

Parent/Legal Guardian Employer*

Hourly Wage*

Hours per week*

Pay Frequency*

Spouse/Partner Information

Spouse/Partner Name

First Last

Spouse/Partner Employer

Hourly Wage

Hours per week

Pay Frequency

Household Income Information

Do you file taxes?*

Yes
No

If no, why not?*

If yes, what is the exact amount of Adjusted Gross Income on your most recent return? This is NOT the Tax Refund amount.*

Additional Household Income per month (if none, type $0.00):

Cash Assistance (if none, type $0.00):*

Child Support (if none, type $0.00):*

Death Benefits (if none, type $0.00):*

Disability (if none, type $0.00):*

Food Stamps (if none, type $0.00):*

Military (if none, type $0.00):*

Retirement (if none, type $0.00):*

SSI (if none, type $0.00):*

Unemployment (if none, type $0.00):*

Brief description of why you need our help: (Include dates of service, provider(s) name and treatment received/needed.)*

Acknowledgement

By completing this form, you acknowledge and agree to the following statements: This form is an eligibility assessment only. This means that completing this form does NOT guarantee the Jones Foundation's grant of any financial grant to your child(ren). The information provided on this form may be reviewed by Jones Foundation staff and its board members to determine eligibility for your child(ren)'s financial grant. The information provided in this form is true and accurate to the best of your knowledge and belief. You understand that intentional misstatements or falsification will render your child(ren) ineligible for a grant.

Electronic Signature

Please Type your First and Last Name*

Date

*

I understand that checking this box constitutes a legal signature confirming that I acknowledge and warrant the truthfulness of the the information provided in this document.

Step 1 of 2

Your child is not eligible.

Please click Next to proceed with the assessment.