Hope Foundation of the Mahoning Valley

Legal Guardian name

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First Name

Last Name

Your Email

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Verify Email

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Patient Information

Patient Name

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First Name

Last Name

Patient date of birth

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(mm/dd/yyyy)

Patient Social Security Number

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Patient Address

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Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

Country

Legal Guardian Information

Legal Guardian Type

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"Other" Legal Guardian

Marital Status

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Number of Dependents

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Legal Guardian Phone

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Legal Guardian Home Address

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Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

Country

Legal Guardian Company/Employer

Legal Guardian Company/Employer Address

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

Country

Mailing address is different from above

Mailing Address (if different from above)

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

Country

Diagnosis

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Receiving Treatment?

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Physician Name

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First Name

Last Name

Social Worker Name

First Name

Last Name

Treatment Facility

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Treatment Facility Phone

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Requested Information

Purpose of Assistance (one sentence, please)

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Beginning date

If applicable, beginning and ending dates of the assistance:

End date

If applicable, beginning and ending dates of the assistance:

Total amount requested

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Maximum $2,500 for child and $5,000 for organization/non-profit

Submit a written detail on how the funds will be used & a quick background of your child.

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Please limit your response to maximum of 1500 words.

Complete and upload the forms listed below.

HIPPA-Financial Statement Fillable Form (PDF)
Most recent Tax Return
A Signed Letter from your primary physician with the diagnosis.

HIPPA-Financial Statement Fillable Form (PDF)

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Most recent Tax Return

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A Signed Letter from your primary physician with the diagnosis.

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Financial Agreement

www.hopemv.org/terms-conditions/

Submission Review

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I certify that I have read these Terms and Conditions, as stated here within this Programs Agreement, and attest that all the information provided in the Grantee’s application is true and correct. I further understand that any falsification or misrepresentation made in respect to this Agreement and its Application, or any accompanying documents, are subject to the forfeiture of funds, including but not limited to any other forfeiture of goods and/or services presented by the foundation.

Typing your name below will act as your digital signature.

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Financial Assistance - Child

Patient Information

Legal Guardian Information

Requested Information