HELP REQUEST FORM

Help Request Form

Our mission is to provide support to families in the Antelope Valley struggling with the effects of childhood illness and to contribute to pediatric hospitals and charities that make a difference in the community. If your child has a medical condition that would qualify for help, please complete the form and supply the required documents for Cure a Child to evaluate.

PARENT / GUARDIAN:

Parent Full Name*
Parent Email*
Parent Phone*
Parent Address*

Are you currently working?*
YesNo
If yes, what is your current occupation?

ADDITIONAL GUARDIAN:

Guardian Full Name
Guardian Email
Guardian Phone
Guardian Address

Are you currently working?
YesNoN/A
If yes, what is your current occupation?

CHILD INFORMATION:

Childs Name*
Childs Date of Birth*

Please give a summary of your child’s condition and any hardships.*

Is this a new medical condition for your child?*
YesNo

FINANCES:

Are you currently renting or do you own a home?*
RentOwn

How many TOTAL dependent children are living in the home?*

What are your estimated monthly essential expenses?*
(Rent, Gas, Electric, Water)

REQUIRED DOCUMENTS:

1. If you currently rent please attach the lease agreement. Tenant’s name and address must be visible. 2. Proof of residency by providing (2) utility bills (Gas, Electric, Water) 3. Proof of child’s residency (School District Records or Medical Supply Shipping Label) Attach up to 5 (2MB max) documents here, or email to [email protected] : png, gif, jpg, jpeg, doc and pdf file types only.

*An in-person interview will be required.
*It will also be required to bring the child’s birth certificate at that time.
If you have questions please call or text 661-810-9086.

HELP REQUEST FORM