Kidneys For Kids Grant Application
(Piliminary Intake Form) Assistance Requested by
Address and Phone # Both Required
Grant Amount Requested (Limit-$1000 per calender year)
Reason(s) For Grant Request:
Please provide us your total monthly living expenses (you will be asked to provide supporting documents before grant is issued)
Less than $500
Between $500 and $1,000
Between $1,000 and $2,000
More than $2,000
Total family income for the last three (3) months (Proof Of Income will be verified)
Please check if you receive or have any of the following additional resources
Commercial Insurance
Veteran’s
Champus/Tricare
Medicare
Medicaid
SNAP
Food Stamps
Other:
Provide costs of yours or your child's treatment, state hospital provider,and costs not covered by any of the above options.
(Costs Examples): Treatment of kidney disease, prescriptions, travel for treatment, lodging during transplant, lost income after donating, transplant costs not covered by insurance.
Email Address Required
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