We Help You And Your Family Feel Better

Patient Name *

First Name

Last Name

Preferred Phone Number of Caregiver

(###)

###

####

Secondary Phone Number of Caregiver, If Applicable

(###)

###

####

Address for Child and Primary Caregiver Who Lives With Child

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Mailing Address for Child and Primary Caregiver if Different from Above

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Is The Mailing Address a Secure Location For Receiving Deliveries of Gift Cards and Packages?

Yes

No

Check One Of The Following To Explain The Amount of Medical Insurance The Child Has.

Providing the following information is optional but strongly encouraged, as it will assist Eliana's Light in obtaining grants for specific, targeted demographics. Disclosing this information has no effect on services granted.

Insured

Uninsured

Underinsured

Check One Of The Following To Explain The Child's Race/Ethnicity.

Providing the following information is optional but strongly encouraged, as it will assist Eliana's Light in obtaining grants for specific, targeted demographics. Disclosing this information has no effect on services granted.

African American

Asian

Caucasian

Hispanic/Latino

Native American

Other

Check One of the Following To Explain The Marital Status of the Child's Primary Caregiver

Providing the following information is optional but strongly encouraged, as it will assist Eliana's Light in obtaining grants for specific, targeted demographics. Disclosing this information has no effect on services granted.

Single

Married

Significant Other/Partner

Widow

Check One of the Following To Explain The Child's Household Income Level

Providing the following information is optional but strongly encouraged, as it assists Eliana's Light in obtaining grants for specific, targeted demographics. Disclosing this information has no effect on services granted.

Under $25,000

$25,000 - $49,999

$50,000 - $74,999

$75,000 - $99,999

$100,000 or more

Address of Secondary Care and Treatment Facility, If Applicable

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Are you receiving services from HSC Home Care? *

If you are unsure, please visit their website: www.hschealth.org/home-care

Yes

No

Are You Comfortable Sharing Your Family's Story? *

If you check "yes", we believe you will inspire others to support Eliana's Light. Therefore, we'll be able to help other families like yours. We'll send you a short questionnaire to complete.

Yes

No

Please Select Which Type(s) Of Support You Would Like To Receive From Eliana's Light *

You may select more than one. Please note that Eliana's Light is unable to provide financial assistance for rent, mortgage payments, utilities, medical co-payments, prescription payments, clothing, transportation, or child care at this time.

Toys/games for children

Lightly used clothes and/or books

Relaxation tools for adults (e.g. yoga mat, foot massage roller, aromatherapy heat wrap for shoulders, etc.)

Financial support for household, transportation/parking, and/or food needs

Arts & crafts supplies/kits

Please Click "Yes" Below If You Have Read, Understood and Agreed To the Downloadable Child/Family Liability Release and Privacy Protection *

Your application will only be considered if you select "yes".

Yes

No