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DATE: _______________________________________
CHILD NAME: _______________________________
CHILD DOB: _______________________________
GENDER: ______________________________
HOME ADDRESS: (Include City, State and Zip)
____________________________________________
____________________________________________
____________________________________________
EMAIL: _______________________________
HOME PH: ______________________________
CELL PH: ______________________________
HOSPITAL NAME: ____________________________
HOSPITAL ADDRESS: (List City & State only)
__________________________________________________
PHYSICIAN NAME: ____________________________
PHYSICIAN ADDRESS:
____________________________________________
____________________________________________
PHYSICAN CONTACT NUMBER:
____________________________________________
DIAGNOSIS:
____________________________________________
____________________________________________
____________________________________________
NOTES ON ILLNESS
(ATTACH A SEPARATE PIECE OF PAPER IF NECESSARY):
____________________________________________
____________________________________________
____________________________________________
____________________________________________
SPECIFICALLY OUTLINE THE TYPE OF ASSISTANCE REQUESTED:
(ATTACH A SEPARATE PIECE OF PAPER IF NECESSARY):
___________________________________________
__________________________________________
__________________________________________
__________________________________________
ARE YOU CURRENTLY RECEIVING ASSISTANCE FROM ANY OTHER ORGANIZATIONS? _______
IF YES, PLEASE LIST THE ORGANIZATIONS THAT YOU ARE CURRENTLY RECEIVING ASSISTANCE FROM:
_______________________________________
_______________________________________
NAME OF MOTHER: ____________________________
MOTHER PRESENT EMPLOYER:
____________________________________________
POSITION: __________________________________
TIME WITH EMPLOYER: _______________________
GROSS MONTHLY INCOME $___________________
OTHER MONTHLY INCOME $___________________
SOURCE OF OTHER INCOME __________________
___________________________________________
PARENTS/GUARDIAN MARITAL STATUS
__MARRIED __DIVORCED__UNMARRIED__SEPARATED
RESIDENTIAL STATUS
__OWN FREE & CLEAR __LIVE W/RELATIVE __OTHER
__OWN W/MORTGAGE
MORTGAGE CREDITOR _________________________
AMOUNT OF MONTHLY MORTGAGE PAYMENT $__________
__RENT
AMOUNT OF MONTHLY RENT PAYMENT $_______________
NAME OF FATHER: ____________________________
FATHER PRESENT EMPLOYER:
____________________________________________
POSITION: __________________________________
TIME WITH EMPLOYER: _______________________
GROSS MONTHLY INCOME $___________________
OTHER MONTHLY INCOME $___________________
SOURCE OF OTHER INCOME __________________
___________________________________________
ALTERNATE CONTACT: _______________________
ALTERNATE PH: _____________________________
BANK: _______________________________________
CHECKING ACCT. __Y__N SAVINGS ACCT. __Y__N
ASSETS
CASH ON HAND $__________ STOCKS/BONDS ____
BUSINESS OWNED ____ 401K/IRA______________
AUTO ________________________________________
CASH VALUE $_________________________________
TOTAL ASSETS _______________________________
LIABILITIES
2ND MORTGAGE CREDITOR ____________________
2ND MORTGAGE BALANCE $____________________
2ND MORTGAGE PAYMENT $___________________
AUTOMOBILE CREDITOR ______________________
AUTOMOBILE BALANCE $______________________
AUTOMOBILE PAYMENT $______________________
AUTOMOBILE CREDITOR ______________________
AUTOMOBILE BALANCE $______________________
AUTOMOBILE PAYMENT $______________________
OTHER HOUSEHOLD INCOME
____________________________________________
____________________________________________
APPLICANT NOTES
____________________________________________
____________________________________________
____________________________________________
____________________________________________
I CERTIFY THAT THE STATEMENTS CONTAINED HEREIN ARE TRUE. I/WE AUTHORIZE THE SETH FOUNDATION TO CHECK ANY INFORMATION IT DEEMS NECESSARY FOR CONSIDERATION OF THIS REQUEST.
___________________________________________
APPLICANT SIGNATURE DATE
___________________________________________
CO-APPLICANT SIGNATURE DATE
THE SETH FOUNDATION
204 INVERNESS LANE
BROUSSARD, LA 70518
337.857.7819 PH/FAX
WWW.THESETHFOUNDATION.COM
EMAIL: sethfoundation@bellsouth.net
AUTHORIZATION FOR THE RELEASE OF MEDICAL RECORDS
NAME OF CHILD: ________________________
NAME OF GUARDIAN/PARENT: _____________
CHILD BIRTH DATE: ____________________
CHILD SOCIAL SECURITY NUMBER: ________
I authorize the release of medical records and medical information for the patient listed above to THE SETH FOUNDATION for the purpose of verifying medical diagnosis/prognosis of patient listed above. This hereby releases THE SETH FOUNDATION from all legal responsibility or liability which may result from the release of my medical records.
DATE: ______________
SIGNATURE: ____________________________
WITNESS: ___________RELATIONSHIP: __________
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