Assistance Application

Child's Name *

First Name

Last Name

Child's Date of Birth *

MM

DD

YYYY

Mother's Name *

First Name

Last Name

Father's Name *

First Name

Last Name

Home Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Is your child a patient at Children's of Alabama? *

Yes

No

Has your family received assistance? *

Yes

No

Phone *

(###)

###

####

I authorize Hope for Autumn Foundation and its agents and representatives to contact Children's of Alabama social workers and medical staff in order to verify my child's diagnosis. *

Yes

I authorize Children's of Alabama to release to Hope for Autumn Foundation and its agents and representatives any information and medical records deemed necessary by Hope for Autumn Foundation to complete its verification of my child's diagnosis. *

Yes

I attest that the information provided above and accompanying this application is true and correct to the best of my knowledge. I acknowledge that Hope for Autumn Foundation will pursue and is entitled to restitution for a grant if it is determined that the information submitted on this application is false. *

Yes

Would you be willing to share your story or part of your story with our generous donors to assist in the fundraising process? No last names will be used.

Yes

No