Date of Application
MM
DD
YYYY
Patient Date of Birth
MM
DD
YYYY
Patient Legal Name
First Name
Last Name
Patient Preferred Name
Patient Gender
Female
Male
Other
Prefer Not to Answer
Date of Patient Injury/Diagnosis
MM
DD
YYYY
Nature of Injury
Check all that apply:
Primary Medical Diagnosis
Case manager to attach recent case note or other supporting documentation
Parent/Guardian Name
First Name
Last Name
Relation to Patient
Mother
Father
Legal Guardian
Step Parent
Other
Home Mailing Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Daytime Phone
(###)
###
####
Alternate Phone
(###)
###
####
Email
Employer
Occupation
Annual Income
<$50,000
$50,000 - $100,000
$100,000 - $200,000
>$200,000
Name
First Name
Last Name
Affiliated Hospital
Children’s Healthcare of Atlanta (CHOA)
Shepherd Center
Other
If Other (Please Specify Below)
Daytime Phone
(###)
###
####
Fax
Email
I have obtained an authorization to release and obtain protected medical information on behalf of my patient/client
Name
First Name
Last Name
Affiliated Hospital
Other (Please Specify Below)
Daytime Phone
(###)
###
####
Fax
Email
I have...
Request
Amount Requested
Provider Name
Provider Contact
First Name
Last Name
Provider Phone
(###)
###
####
Provider Email
How will this request allow the applicant to live their life more fully?
If the service or good you are requesting costs more than Andee’s Army provides, how will you pay for the remaining cost if approved for an Andee’s Army grant?
Checkbox
Who referred or introduced you to Andee’s Army?
Have you received assistance from Andee’s Army in the past?
If Yes, please list the date and amount of grant awarded.
Have you applied for assistance from other organizations?
If yes, please list the other organizations you've applied to for assistance.
