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.

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

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

Spouse/Partner Information

Household Income Information

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

Acknowledgement

Electronic Signature