Applications must be completed and submitted by a professional healthcare provider. For grant consideration, please complete the following application and click SUBMIT.

The Health Insurance Portability and Accountability Act legislation (HIPAA), now requires a signed HIPAA-compliant patient authorization before transferring a patient's Protected Health Information (PHI) for this purpose. If this requirement applies to you as a covered entity, a printable HIPAA authorization form is available for your convenience by choosing a format on the left.

Applications are subject to a Selection Committee and Board of Directors review. The Selection Committee meets on a monthly basis, at which time grant applications are reviewed. You will be notified in writing as to whether or not your request has been granted.

Select One Yes No A signed HIPAA-compliant patient authorization form is required to transfer
patient information/PHI to Growing Family Foundation

Application Date:
9/2/2010

Grant Recipient Information

Mom's Name Dad's Name
Street Address
City
State/Province Select State AA AE Alabama Alaska AP Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington, D.C. West Virginia Wisconsin Wyoming Alberta British Columbia Manitoba New Brunswick Newfoundland Northwest Territories Nova Scotia Ontario Prince Edward Island Quebec Saskatchewan Yukon American Samoa Guam Zip/Postal Code
Marital Status Single Married Divorced
Employment Status Yes No

Household Income

Less than $10,000
$10,000 - $25,000
$25,000 - $50,000
$50,000 - $75,000
$75,000 - $100,000
$100,000+

Number of Siblings at home

1
2
3
4
5 or more

Insurance
Private Group through employer Medicaid Other
If other, please list

Other means of financial assistance
WIC SSI TANF Other
If other, please list

Applicant Name
Relationship to Baby

Information on Recent Birth
Date of Birth Pick Date
Hospital
City, State/Providence

Provide specific details in support of the grant


Grant would be used for
Baby Care Items Car Seat/Stroller Special Formula
Transportation to Doctor Gasoline Medical Equipment
Medical Expenses Home Healthcare Utilities
Mother Unemployed Father unemployed

Professional Healthcare Provider Information

Dr Mr Ms Mrs
First Name
Last Name
Title
Hospital Name
Hospital Address
City
Email
State/Province Select State AA AE Alabama Alaska AP Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington, D.C. West Virginia Wisconsin Wyoming Alberta British Columbia Manitoba New Brunswick Newfoundland Northwest Territories Nova Scotia Ontario Prince Edward Island Quebec Saskatchewan Yukon American Samoa Guam Zip/Postal Code
Hospital Phone Number () -

Hospital President

Dr Mr Ms Mrs
First Name
Last Name

For Foundation Use Only

Selection Committee Review Date: Pick Date Accepted Grant Amt $ Rejected
Selection Committee Review Date: Pick Date Date Paid: Pick Date