Step 1 of 2 50% Eligibility AssessmentAre you applying for yourself or for your child?*MyselfChildapplicantIs child a US Citizen?*YesNoIs child under age 21?*YesNoIn which county does the child reside?*Coffey County, KansasLyon County, KansasOsage County, KansasElsewhereHas child resided in the county continuously for a minimum of one year?*YesNoThe child is not eligible. The child must be under age 21, must be a US Citizen and must currently reside in Coffey, Lyon, or Osage County Kansas and have done so continuously for no less than one year immediately prior to application. Return to Home PagePlease click Next to proceed to the application. Are you renewing a previously approved application?*YesNoApplicant InformationLegal Name* First Last Last 4 digits of SSN*Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Date of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Age*Sex*MaleFemaleDaytime Phone*Applicant Email* If Jones Foundation needs to contact you, would you prefer...*PhoneEmailParents/Legal Guardian(s) contact information with whom applicant resides (if applicable)Name:* First Last Relationship to Patient*Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Daytime Phone*Parent/Legal Guardian Email* If Jones Foundation needs to contact you, would you prefer...*PhoneEmailCertificationThe applicant above has been diagnosed with Type 1 Diabetes, and I am requesting assistance with expenses associated with his/her treatment. I hereby give permission to the staff of the Jones Foundation to contact the parties listed in this application or attachments thereto for purposes of verification. I am acknowledging that both the Applicant and Parent/Legal Guardian (if applicable) have resided for a minimum of one year prior to application date and that residency must be maintained in Coffey, Lyon, or Osage County to remain eligible for this Jones Foundation grant.Signature of Parent/Legal Guardian or Applicant (if age 18-20)*Date* Date Format: MM slash DD slash YYYY
