Diabetes Expense Grant Application

Are you renewing a previously approved application?*

Yes
No

Applicant Information

Legal Name*

First Last

Last 4 digits of SSN*

Address*

Street Address City State ZIP

Date of Birth

Age

Sex*

Male
Female

Daytime Phone*

Applicant Email*

If Jones Foundation needs to contact you, would you prefer...*

Phone
Email

Parent or Guardian contact information with whom applicant resides

Name:*

First Last

Relationship to Patient*

Address*

Street Address City State ZIP

Daytime Phone*

Parent or Guardian Email*

If Jones Foundation needs to contact you, would you prefer...*

Phone
Email

The child 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 authorized Person and Applicant 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 or Guardian*

Signature of Applicant (if age 18-20)*

Date*

Step 1 of 2

The child is not eligible.

Please click Next to proceed to the application.

Applicant Information

Parent or Guardian contact information with whom applicant resides