Buying-Time Grant

This grant’s purpose is to cover some financial strain for the family who is going through the unimaginable. We believe that no child should fight their illness alone, no matter the hardship. We want to buy time so the family can spend as much time with their child as possible, instead of at work making ends meet. Families need all the help they can get to remain family strong!

Qualifications

Child MUST be under the age of 18
Child MUST be terminally ill
Child MUST have a prognosis of 6 months or less.
This grant does not exceed 6 months.
This grant does not exceed $2,500.
Financial assistance must be acquired during child illness
Child, and family, must be represented by a social worker

Requirements

A social worker or medical professional to fill out the intake on their behalf
Social worker to verify and investigate financial need. (annual income, other pursued resources & other financial aid, crowdfunding etc.)
A copy of the bill, with accurate account information, to be used to make the payment
Alana Rose Foundation MUST be notified when the child passes.
A family who meets all of the qualifications

If you meet all of the above qualifications and requirements, please fill out your information below. If not, please go to our General Intake Form.

By filling out this form, you give The Alana Rose Foundation permission to discuss the information provided with the child's doctor, social workers, and personnel at The Alana Rose Foundation. We do not share your information with third parties nor sell any information that you provide.

Family Information
Name*
First Last
Address*
Street Address Address Line 2 City State ZIP Code
Phone*
Email*
Enter Email Confirm Email
Social Worker
Name of Social Worker*
First Last
Agency or Government Office Name
Agency or Government Office Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Email*
Enter Email Confirm Email
Phone*
Child's Illness
Child's Medical Diagnosis*
- Terminal
- Life-Threatening
- Pending Diagnosis (High-Risk/Life-Threatening)
Please explain.*
Child's Prognosis?*
How long has the child been hospitalized?*
Financial Assistance
Reason for Assistance (explain in detail):*
What is the total annual combined family household income?*
What is the Parent/Guardian's employment status?*
- Unemployed
- Employed
- Medical Leave
How has the child’s illness affected their ability to work?*
Have there been other resources sought out for this case?*
- Yes
- No
Please explain what resources and how much has been awarded.*
Does the family currently have a crowdfunding website that they're using?*
- Yes
- No
Please Enter The Crowdfunding Campaign URL Below*
What are the living arrangements?*
- Rent
- Own
- Staying with Family
- Hotel/Motel
What would be the biggest financial relief (for up to 6 months) during their child's illness?*
Applying for Bill/Invoice Payment?*
- Yes
- No
Please provide a copy of the bill/invoice requested.*
Drop files here or

Accepted file types: jpg, gif, png, pdf.
Is there any other information we need to make the payment?*
- Social Security Number
- Login Information
- Pin Number
- Other
Please Provide Necessary Information
If additional information is needed to give assistance, who can we contact about the bill? (Provide name, email, and phone number)*
First Last
Email*
Enter Email Confirm Email
Phone*
What is the best contact method for sharing the bill payment log?*
We have a log that we use to document our payment history.
- Phone
- Email
- Other
Phone
Email
Enter Email Confirm Email
Please name other contact method.
Who will contact us when the child joins Alana and the other angels in heaven?*
First Last
Other
Is there anything we can help with besides financial assistance toward a bill? For example, a remembrance item/jewelry, photo session, etc.*
- Yes
- No
If so, please provide us with all the details, shipping, and links to make the purchase.*
Confidentiality Release
All information is needed for assistance purposes ONLY.

Account information will be discarded after payment, excluding confirmation numbers and receipts.

No other parties/individuals will have access to this information.

We will not ask for more information while accessing your account on your behalf.
Consent Release
Does the family give Alana Rose Foundation permission to access their account on their behalf to pay the bill?*
- Yes
- No
Does the family give Alana Rose Foundation permission to speak with their attending Social Worker to discuss their case?*
- Yes
- No
Do you give Alana Rose Foundation permission to anonymously summarize the case for our own purposes (social media, our impact, family counts, etc.)?*
- Yes
- No
- Not sure, please call to discuss
Is the family willing to write a short and anonymous testimonial on how we’ve helped them?*
- Yes
- No
I agree to give The Alana Rose Foundation permission to perform additional research on family finances, financial obligations, contact payee(s) to request balances and to make payment, and pay bills on my behalf.*
- I agree
Message / Additional Comments
Additional Photos
Drop files here or

Accepted file types: jpg, png, pdf.
CAPTCHA
Name
This field is for validation purposes and should be left unchanged.

Save and Continue Later

Buying-Time Grant

Qualifications

Requirements

Family Information

Social Worker

Child's Illness

Financial Assistance

Other

Confidentiality Release

Consent Release