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Application for Financial Aid  

 

PATIENT Information
Please provide details on the patient for which aid is being applied for.
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First Name
Last Name
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(mm/dd/yyyy)
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Address Line 1
Address Line 2
City
State/Province
ZIP/Postal Code
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Please provide past or current Employer


Address Line 1
Address Line 2
City
State/Province
ZIP/Postal Code
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Address Line 1
Address Line 2
City
State/Province
ZIP/Postal Code

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If this form is being submitted by someone other than the patient, I certify that I am authorized to act on behalf of the patient and provide/discuss their medical condition.  If you are someone other than the patient, spouse, parent, or helath care provider a notarized Power of Attorney may be required for consideration of this application and discussion of a potential grant award.

As a secondary means of getting to know our applicants better, and in an effort to make the best decsions regarding where we distribute funds, our application process will include a virtual interview with the patient, caregiver, and/or other family members submitting this application.  Doing so affords us the opportuinity to get to know you better, allows you to get to know us better, and provides the opportunity to connect in a manner beyond what is possible in a written application.  

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First Name
Last Name

please provide the best email address to schedule this video interview


Video Interviews typically last 20-30 minutes
Insurance & Finances
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Name of insurance company





Income

What was your total HOUSEHOLD income for:




What is your monthly income from the following sources:














Expenses:

Please list your approximate MONTHLY expenses for:









Kim's Hope reserves the right to request further financial information, includiong prior W2 of 1040 tax forms to ensure the aid we distribute is received by those with the most need.  By entering my name below, I certify that the financial information conatined on this application is true and accurate, and agree to provide addtional information as requested by Kim's Hope. 

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First Name
Last Name
Medical Information
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(mm/dd/yyyy)

(mm/dd/yyyy)
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Please provide documentation showing physician-confirmed diagnosis of glioblastoma
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biopsy, resection, ablation, etc.
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Please provide details and timeline of the patient's journey from initial diagnosis to present time (include all treatments completed and successes/failures of those treatments as well as any alternate or addtional treatment plans under consideration)

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Additional Information

We would love to get to know the patient and their care team, and the personal side of your stories outside of the GBM diagnosis.  Please tell us about your career(s), your personal interests, your family, your faith, and anything else you can share that would give us a better picture of your life both before and after diagnosis.  We love to receive pictures as a supplement to your application which cvan be attached below or emailed to todd.veenhuis@kimshope.org

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Kim's Hope requests the ability to highlight the stories of our recipients on our website, social media stories, newsletter, and other promotional materials.  Only those that are awarded aid will be included.  Please indicate your willingness to have your strory and pictures used on future Kim's Hope materials to help advance our mission of providing aid to  maore families in need and to help build awareness of glioblastoma and the families fighting against it.

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I certify that all information contained within this applciation is accurate to the best of my knowledge and that I will provide addtional information requested by Kim's Hope if necesary to complete the application process. 

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First Name
Last Name
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