General Grant

Jake’s Help from Heaven, founded in 2011, is a non-profit that creates opportunities for those with complex medical challenges and physical disabilities to thrive.

Reimbursement App: Once approved for ongoing reimbursement, applicants are required to submit itemized receipts along with a completed reimbursement form for each request.

Grant Eligibility:

Grants are limited to individuals living within the following New York counties: Saratoga, Hamilton, Warren, Washington, Rensselaer, Albany, Schenectady, Montgomery, and Fulton.
Grants are restricted to individuals of any age with complex medical needs and physical disabilities resulting from congenital or childhood-onset
There is a $1,500 cap per applicant per calendar year.
Priority is given to repeat applicants.

INCOMPLETE APPLICATIONS WILL NOT BE SUBMITTED TO THE BOARD OF DIRECTORS FOR CONSIDERATION. THE FOLLOWING CRITERIA MUST BE MET:

A post-appointment letter or complete discharge notes from the treating doctor indicating reason(s) for treatment and the treatment dates.
Completed Expense Worksheet with all columns totaled.
Completion of the following application with the signature of a pediatrician/primary care doctor, social worker, or care worker.
Receipts for reimbursement.
To be eligible for reimbursement, the travel must have taken place within one year of the date that the application is being reviewed.
Applicants should submit their completed applications with all required documents at one time, and not in separate pieces.
Electronic applications must be submitted in PDF format. We DO NOT accept jpegs or screenshots.
If you receive your requested funds elsewhere, please alert us immediately so that we can withdraw your application. Failure to do so may affect your eligibility to apply in the future.
Please double-check that the applicant’s address is listed correctly. JHFH is not responsible for replacing reimbursements mailed to the wrong address due to errors on the application.
When individuals other than the applicant are completing the application, please write in the third person and do not write in the applicant’s voice.

Jake’s Help From Heaven General Application

Section A: Personal Information

Applicant(Required)

First Last

Age(Required)

Please enter a number from 1 to 150.

Parent/Guardian (if applicable)

First Last

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Daytime Phone #(Required)

Evening Phone #(Required)

Email(Required)

Contact information for the individual completing the application (if different from applicant/guardian)

Name

First Last

Relationship to Applicant

Phone

Describe your medical condition and the hardships it creates.(Required)

Section B: Application Details

Grant amount requested

WHICH TYPE OF PAYMENT ARE YOU SEEKING? CHECK ONE

Reimbursement for an item/service that has already been purchased

Direct payment to a vendor for an item/service that has NOT already been purchased

List item(s) you are requesting funding or reimbursement for

Describe the item. How does your medical condition relate to a need for this item?

How do you expect to use this item (for what purpose, how often, where etc.)

In what ways will this contribute to an increased quality of life for the applicant and family?

A doctor's prescription and/or letter of medical necessity is REQUIRED. You may upload your documents here or mail your documents in.

Doctor's prescription and/or letter of medical necessity(Required)

Drop files here or

Accepted file types: jpg, pdf, Max. file size: 2 GB.

Receipts of purchased items OR vendor information for item to be paid directly by Jake's Help from Heaven is REQUIRED. You may upload your documents here or mail your documents in.

Receipts of purchased items OR vendor information for item to be paid directly by Jake's Help from Heaven(Required)

Drop files here or

Accepted file types: jpg, pdf, Max. file size: 2 GB.

Section C: Disclosure/Signature

I declare that the information provided on this application for financial assistance is true and complete to the best of my knowledge. I understand that what I submit to Jake’s Help from Heaven is for the purpose of financial reimbursement for or direct purchase of medically necessary or convenient items and services. I understand that I may be required to provide additional evidence of submitted information, including a current income tax return or other financial information. I give permission to Jake’s Help from Heaven to contact the provided medical facility for verification purposes. I agree to allow Jake’s Help from Heaven to use my name in announcements and related publications.

Signature of Applicant or Parent/Guardian:(Required)

Printed name of Applicant or Parent/Guardian(Required)

First Last

Date(Required)

You may upload a photo or a scan of a signed document from your doctor with the endorsement saying "I (social worker or primary doctor) support (applicants name) application for (requested item) on (date)” or use the save and continue option and send your social worker or primary doctor the link for them to sign. After adding their signature, your doctor or social worker must then use the save and continue option and send you the new link to your form.

Signature of social worker or primary doctor

I support (applicants name) application for (requested item) on (date)”

Scanned signature of social worker or primary doctor

Accepted file types: jpg, pdf, Max. file size: 2 GB.

Printed name of social worker or primary doctor(Required)

First Last

Contact phone number or email for the doctor/social worker(Required)

Date

General Grant

Jake’s Help From Heaven General Application

Section A: Personal Information

Section B: Application Details

A doctor's prescription and/or letter of medical necessity is REQUIRED. You may upload your documents here or mail your documents in.

Receipts of purchased items OR vendor information for item to be paid directly by Jake's Help from Heaven is REQUIRED. You may upload your documents here or mail your documents in.

Section C: Disclosure/Signature

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