Family Assistance Program Application

Application for Childcare Support for Families of Children with Cystic Fibrosis

Date Date / MM / DD YYYY
Family Information
Parent/Guardian Name #1 Parent/Guardian Name #1 First Last
Parent/Guardian Name #2 Parent/Guardian Name #2 First Last
Patient Name Patient Name First Last
Age
Family Address Family Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Phone #1 Phone #1 - ### - ### ####
Phone #2 Phone #2 - ### - ### ####
Email #1
Email #2
Medical Information
Name of Physician Treating the Patient for CF Name of Physician Treating the Patient for CF First Last
Clinic or Hospital Name:
Phone Phone - ### - ### ####
Please detail how many clinic appointments you and your child attend each year (to the best of your ability):
Has the patient been recently hospitalized for cystic fibrosis complications?
Date of hospital admittance Date of hospital admittance / MM / DD YYYY
Number of days in hospital
Family Need Information
Family Monthly Gross Income
Please list the names and ages of all members of your household:
When arranging childcare for other siblings while your child with CF is attending clinic, what kind of childcare do you use?

When arranging childcare for other siblings while your child with CF is attending clinic, what kind of childcare do you use? Family Member Babysitter/Nanny Childcare Center/School
Describe your family's need for assistance with childcare:
Please describe how you would want to use this support (frequency and type of childcare you would want to use):
Signature and Acknowledgment
By submitting this application, I hereby authorize the Vivian Lee Foundation to obtain my protected health information. This medical authorization hereby authorizes your medical provider to speak with Vivian Lee Foundation and have access to all your medical records on your child. The authorization is obtained for this transaction only. The authorization expires when this transaction is complete.

I verify that the information provided in this application is complete and accurate. I also understand the Vivian Lee Foundation reserves the right at any time and without notice to modify the assistance and discontinue any or all of the programs and related eligibility criteria at any time.
Draw your signature into the box below.

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.

Family Assistance Program Application

Family Assistance Program Application

Family Information

Medical Information

Family Need Information

Signature and Acknowledgment