info@jakeshelpfromheaven.org

Jake’s Help from Heaven Repeat General Application

Jake’s Help From Heaven welcomes applicants of all ages living within 100 miles of Saratoga Springs, NY.

We also reimburse or purchase directly items which positively impact the life of the medically fragile individual. We understand the importance of proper equipment, accessories and items which can improve the quality of the applicant’s life. Items can be of medical necessity or medical convenience. More information and the application can be found here:

JHFH REPEAT 2024

Grant Eligibility:
• Grants are limited to individuals living within 100 miles of Saratoga Springs, New York.
• Grants are restricted to individuals with complex medical needs and disabilities resulting from
congenital or childhood-onset diseases. Applicants of all ages with lifelong, debilitating illnesses
are welcome to apply.
• This application can only be used for general requests by individuals who have previously
applied, have not reached the $2,500 calendar year cap, and have not had a change in diagnosis.
• Repeat applicants are for GENERAL requests only. Repeat travel and technology requests must
still be made through the Travel or Technology Applications.

AS OF 2024, INCOMPLETE APPLICATIONS WILL NOT BE SUBMITTED TO THE BOARD OF
DIRECTORS FOR CONSIDERATION. THE FOLLOWING CRITERIA MUST BE MET:

• Completion of the following application with the signature of a pediatrician/primary care doctor
or social worker.
• A doctor’s prescription and/or a professional letter of medical necessity by a doctor, therapist, or
teacher. The leters of medical necessity must be signed and dated, preferably on leterhead.
• Proof of payment is required for reimbursement or vendor information for direct purchase. We
do not award money for general donations or support.
• To be eligible for reimbursement, items and services must have been purchased within one year
of the date 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.
• There is a $2,500 cap per applicant per calendar year. Applicants may apply multiple times
within a calendar year but are only eligible to be awarded a total of $2,500 within that year.
• If you receive your requested item 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.

IN ADDITION, PLEASE NOTE THE FOLLOWING POLICY CHANGES:

• If the primary letter of medical necessity was written by the individual or practice providing the
requested service, we require a second letter or script from a disinterested medical provider.
• Please be precise when providing product information. JHFH is not responsible for
returning/exchanging incorrect items that resulted from a mistaken request.
• Please double-check that the applicant’s address is listed correctly. JHFH is not responsible for
replacing items mailed to the wrong address due to errors on the application.
• Applicants requesting a grant of over $1,000 may be asked to submit a current income tax return
or other financial information.
• 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 Repeat Applicant Program 2024

Applicant:(Required)
Parent/Guardian’s Name:(Required)
Address(Required)
Contact information for the individual completing the application (if different from applicant/guardian):
Name
MM slash DD slash YYYY
Was it approved?(Required)

Section B: Application Details

Which type of payment are you seeking? Check one

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

Drop files here or
Accepted file types: jpg, pdf, Max. file size: 2 MB.

    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.

    Drop files here or
    Accepted file types: jpg, pdf, Max. file size: 2 MB.

      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 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.

      Parent’s name printed(Required)
      MM slash DD slash YYYY
      Primary Doctor or social worker(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.

      Max. file size: 2 MB.
      MM slash DD slash YYYY
      This field is for validation purposes and should be left unchanged.