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Second Chance Kids Application
To apply for assistance, either for yourself or on someone's behalf, please fill in our application below.
Note: You will receive an email copy of your application upon submission.
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* Indicates required question
Email
*
Your email
Name of Child
*
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Parent/Guardian
*
Your answer
Siblings, if any
Your answer
Address
*
Your answer
City
*
Your answer
Postal code
*
Your answer
Phone
*
Your answer
Email
*
Your answer
Date of Admission
*
MM
/
DD
/
YYYY
Date of Discharge, if known
MM
/
DD
/
YYYY
Name and City of Hospital
*
Your answer
Reason for Hospitalization
*
Your answer
Referred by
*
Your answer
Date of Referral
*
MM
/
DD
/
YYYY
Involved Doctors/Healthcare Professionals
*
Your answer
Associated Costs
*
Your answer
Other pertinent information
*
Your answer
Consent
*
I/we consent to Second Chance Kids collecting the information
I/we have provided on this form for the purpose of assessing and verifying my/our eligibility to receive funding.
Required
Acknowledgement of Funding
*
I/we understand that in receiving funding from Second Chance Kids all monies will be used only for costs associated in supporting our child at a health care facility out of our local area for primary medical care.
I/we understand these costs may include, but are not limited to, shelter, transportation expenses, parking, and food for my/our child and the caregiver(s).
I/we agree to retain all receipts for audit purposes and shall produce same to Second Chance Kids at any time upon request.
Required
A copy of your responses will be emailed to the address you provided.
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