Family Assistance Program Application

Application for Support for Families of Children with Cystic Fibrosis.
Provided by the Vivian Lee Foundation.

There is a maximum of 6 requests for assistance per year per family.

Date Date / MM / DD YYYY
Family Information
Parent/Guardian Name #1 Parent/Guardian Name #1 First Last
Patient Name Patient Name First Last
Age
How many people total live in your household?
Family Address Family Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Phone #1 Phone #1 - ### - ### ####
Email #1
Medical Information
Name of Physician Treating the Patient for CF Name of Physician Treating the Patient for CF First Last
Clinic or Hospital Name:
Social Worker that can confirm CF diagnosis Social Worker that can confirm CF diagnosis First Last
Direct Phone # of Social Worker (we must have this in order to confirm diagnosis) Direct Phone # of Social Worker (we must have this in order to confirm diagnosis) - ### - ### ####
Direct Email of Social Worker (we must have this in order to confirm diagnosis)
Has the person with cystic fibrosis been hospitalized for illness?
Has the patient been recently hospitalized for COVID-19 and cystic fibrosis complications?
Date of hospital admittance Date of hospital admittance / MM / DD YYYY
Number of days in hospital
Please tell us what your greatest need for assistance is:
Check all that apply.

Please tell us what your greatest need for assistance is:
Check all that apply. Loss of Income due to illness Childcare expenses for clinic and/or hospitalization Living expenses during hospitalization Medical expenses after insurance
Please tell us a little about your family and situation. Do you have a very specific need and amount of assistance?

Please understand that this grant is NOT designed for the following needs:
Food and groceries
Utilities
Transportation
Rental assistance
Living expenses not related directly to CF

We know there are local resources available for these needs. Please contact your CF care team social worker for additional resources.
Please allow 3-4 weeks for your application to be processed. Confirmation of cystic fibrosis diagnosis must be maintained by Vivian Lee Foundation prior to providing assistance money. A check will be mailed to you after confirmation has been determined by Vivian Lee Foundation.

Families with verified CF status may apply for assistance a maximum of 6 times per year.

The Vivian Lee Foundation will determine amount of assistance per family and per application.
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

Signature and Acknowledgment