Date *

Applicant's Name *

Applicant's Age *

Applicant's Address *

Email Address of Patient/Guardian *

Phone Number (Parent/Guardian) *

Applicant Number *

Description of Request *

The Foundation typically supports families with annual income under $75,000 or those experiencing financial hardship.

Select Your Financial Assistance Qualification *

I have my spouse (if applicable) had total annual income for the most recently completed year of less then 75,000, do not reasonably ecpect to exceed such level of income in the current year, and have one or more childres/ dependents.

I and my spouse (if applicable) had total annual income for the most recently completed year of loss than 100,000, do not reasonably expect to exceed such level of income in the current year. and have one or more children/dependents.

I do not meet either of the criteria for financial assistance set forth above but desire to seek financial assistance based on other circumstances or financial hardship. (In addition to providing the information in the table below, you must also provide a reasonably detailed description of our circumstances or financial hardship in the •Additional Information' section below.)

Financial Information

Family Income

Members of Family / Dependents

Salary Before Other Income

Total Family Size

Total Gross Income *

Additional information (must bo completed if you are applying for financial assistance but do not meet either of tho annual Income criteria for assistance):

An IRS Form W-2 or other applicable form must be provided to support the information set forth above. The Foundation may also ask for additional supporting as it determines to be reasonable.You will acknowledge that there is no assurance that you will receive financial assistance, oven if you meet either of the annual Income criteria for assistance. Any and all financial assistance including a determination to grant financial assistance and the amount thereof (If any), will bo determined by the Foundation In its sole discretion based on a variety of factors, Including, without limitation, available funds, the number and needs of other applicants, and other relevant factors as may be considered by the Foundation.