General Intake Form

This intake is to assist families who are facing childhood illnesses that are long term and will endure financial strain due to the illness, hospitalization, and child care. As we know, our assistance won’t solve all of their financial burdens or responsibilities; we believe that our assistance is a gift to these children to allow their parents to spend more time with them while they are fighting for their life. Staying Family Strong is our goal!


  • Child MUST be under the age of 18
  • Child MUST be terminally ill or have a life-threatening illness that is present for longer than 6 months.
  • Financial assistance must be acquired during child illness
  • Family lives in Delaware or Surrounding Areas
  • Child, and family, must be represented by a social worker


  • 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
  • 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 the child has a prognosis of 6 months or less, please go to our Buying-Time Grant.

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.