Wish Request of Person(s)/Family of child with Special Medical Need

Application Process:
  Please fill out this form in its entirety and read carefully.  Any lines left blank will eliminate this request from consideration.  If the question does not apply to you, N/A is the appropriate answer.  The application will be reviewed and voted upon by our full Board.  Approval requires a 2/3 vote of the Board members.   You will be notified of the decision in writing following the vote.

Eligibility Rules:   The person with the special medical need, serious medical condition and/or serious injury must live in Gibson, Posey, Vanderburgh, or Warrick County, Indiana or Henderson County, Kentucky. There must be an immediate and pressing financial need on the family that cannot be met through other means.    

Criteria for Selection:  911 Gives Hope, Inc will base its decisions on availability of funds, priorities assigned to other purposes as stated in its by-laws and evaluation of the application.

Maximum Grant:  The maximum grant per application is $5,000.00.  In specific cases where a special event fundraiser is arranged on your behalf, the maximum grant available will be the amount raised, limited to the amount of your need.  If the amount raised is in excess of your need, the balance will be applied to our general fund to be used to help others.  You may only apply once in a 12 month period.

Provision of Service Statement: 911 Gives Hope, Inc. does not discriminate on the basis of Race, Color, National Origin, Sex, Religion, Age or Disability in provisions of services.
Acknowledgement: I certify that the above information is correct to the best of my ability and hereby authorize 911 Gives Hope, Inc. to request and receive information for verification of the same.