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Please fill out the form below to apply for assistance. NOTE: The more completely you fill out the form the better Hometown Heroes can evaluate your level of need.

Child Information
*Child's Name		Birth Date (mm/dd/yyyy* format)
Spoken Language:	Gender: Male Female
Street Address:	City:
State:	Zip:	County:
Email:		Phone:
Please provide information about your child's diagnosis and describe their life threatening/altering illness or injury:
How has your child's illness/injury affected your family financially:
Contact Information
Mother/Guardian 1 Name:
Home Phone:		Cell Phone:
Mailing Address:
City:	State:	Zip:
Father/Guardian 2 Name:
Home Phone:		Cell Phone:
Mailing Address:
City:	State:	Zip:
Authorized Contacts
I authorize the following person(s) to be contacted and give my permission to turn my child over to this person(s) in case of an emergency and I cannot be reached.
Contact 1 Name:		Relationship:
Home Phone:		Cell Phone:
Contact 2 Name:		Relationship:
Home Phone:		Cell Phone:
Referral Information
How did you hear about Hometown Heroes? Newspaper Ad Internet Friend Magazine Ad Staff Member Brochure Doctor Television Ad Former Recipient Other
Insurance Information
Name of Insurance Company:		Insurance Company Phone:
Doctor & Medical Information
Specialist's Name:	Phone:	Hospital:
Pediatrician's Name:	Phone:
Address:
City:	State:	Zip:
Does your child use/have any of the following (check all that apply): wheelchair crutches walker splint braces artificial limb amputation Other Limitations:

Please let us know how your child's recent history has been. Specifically, describe your child's living situation (who he/she lives with), school situation (how he/she interacts socially and in class), recent hospitalizations and any other major adjustments (change of address, birth of sibling, recent losses, etc.).
Does your child have any special needs (emotional) that you need to share with us?
Please describe any specific challenges your child has
How often does your child require physical assistance at home or in school? All of the time Some of the time None of the time If you answered all of the time or some of the time, please give examples (i.e., when changing, physically transitioning, toileting, etc.).
What are your child's major interests?
Please provide any other information that would be benefitial for us to know to provide the best experience possible.
Non-Family Reference
Please list a non-family contact person for additional psychological/social information (teacher, therapist, child life specialist, etc.):
Name:		Phone:
Acceptance of Terms
I hereby release, discharge and otherwize indemnify Hometown Heroes, its affiliated organizations and sponsors, its officers, directors, employees, volunteers, and agents against any claim by or on behalf of myself or my minor child as a result of my child's participation in any program or activity sponsored, coordinated, or supervised by Hometown Heroes. I also agree to release, discharge and agree to hold harmless and indemify the parties with respect to any medical expenses resulting from personal injuries sustained by the child while engaged in such activities or otherwise. I also understand that this release includes traveling to or from programs or activities. SHARING OF INFORMATION I give permission for my child to share addresses and phone numbers with all other children. PHOTO/MEDIA RELEASE I also give Hometown Heroes, sponsors, and authorized news media permission to photograph and to use pictures, video, or audio tapes of my child either alone or in groups for the newsletter, advertising purposes, fund-raising activities, bulletin boards, or in promoting public understanding and support for children with chronic or life-threatening illnesses or substantially similar puposes. Hometown Heroes respects the privacy of the children and their families and does not give permission for unathorized visitors to photograph children. BY SUBMITTING THIS FORM I CERTIFY THAT I FULLY UNDERSTAND AND AGREE TO THE TERMS STATED ABOVE AND AGREE THAT ALL INFORMATION IS COMPLETE AND CORRECT TO THE BEST OF MY KNOWLEDGE. Submitted By: (please enter your name)

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SHARING OF INFORMATION

PHOTO/MEDIA RELEASE

BY SUBMITTING THIS FORM I CERTIFY THAT I FULLY UNDERSTAND AND AGREE TO THE TERMS STATED ABOVE AND AGREE THAT ALL INFORMATION IS COMPLETE AND CORRECT TO THE BEST OF MY KNOWLEDGE.