Request Assistance

Please submit your requests/needs below. All submissions are reviewed by our board of directors on a monthly basis. Please allow 30 days for requests to be processed. Emergency needs are reviewed on a case-by-case basis.

Parent/Guardian Full Name

2nd Parent/Guardian Full Name

Mailing Address

City

Physical Address

State

Zip

Parent's Email Address

Parent's Home Phone

Parent's Cell Phone

Child's Full Name

Child's Date of Birth

Date of Diagnosis

Official Diagnosis

Affiliated Hospital's Name

Social Worker/Hospital Contact Name

Social Worker/Hospital Contact Phone

Social Worker/Hospital Contact Email

If you have a fundraising page for your child, please provide the link

Please tell us about your child (2,000 max characters)

How did you hear about us?

Check this box if you authorize us to use your child's photo on social media and/or other public or non-public communications and materials.

Check this box if you authorize us to use your child's story on social media and/or other public or non-public communications and materials.

I understand my submission of this form and all information contained herein is voluntary, with the intent to request assistance from Madi's Hope Foundation. Furthermore, I understand my submission of this form is not a guarantee assistance will be provided. All cases are reviewed by the board of directors and if assistance is available I will be contacted. Additionally, I attest the information submitted is true and correct to the best of my ability, and I understand providing false/misleading information will result in the immediate denial of any assistance that otherwise would have been made available.

MADI'S HOPE FOUNDATION

"A helping hand is a healing hand"