Test Applications

Jake’s Help From Heaven Medical Travel Application

Section A: Personal Information

Applicant(Required)
Parent/Guardian (if applicable)
Address(Required)
Please enter a number from 1 to 150.

Section B: Medical Treatment/Services Information

Facility Address(Required)

Section C: Travel Information

Please fill out the Expense Worksheet COMPLETELY. This includes totaling all appropriate columns. You may upload your documents here or mail your documents in.

Travel Expense Worksheet
Accepted file types: jpg, pdf, Max. file size: 2 MB.

A post appointment letter or complete discharge notes from the treating doctor indicating reason(s) for treatment and treatment dates is REQUIRED. You may upload your documents here or mail your documents in.

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

Section E: 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 to enable travel for medical treatment/services. I understand that I may be required to provide additional evidence of submitted information and I give permission to Jake’s Help From Heaven to contact the medical facility for verification purposes. I agree to allow Jake’s Help From Heaven to use my name in announcements and related publications.
Printed name of Applicant or Parent/Guardian(Required)
MM slash DD slash YYYY

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.

I support (applicants name) application for (requested item) on (date)”
Printed name of social worker or primary doctor(Required)
MM slash DD slash YYYY

Jake’s Help From Heaven LOCAL Medical Travel Application

Section A: Personal Information

Applicant Name:(Required)
Please enter a number less than or equal to 130.
Parent/Guardian (if applicable):
Address(Required)

Section B: Medical Treatment/Services Information

Doctor(Required)
Facility Address(Required)
Max. file size: 2 MB.

Section C: Travel Information

Max. file size: 2 MB.

Section D: Disclosure/Signature

Disclosure(Required)
Disclosure(Required)
Disclosure(Required)
Printed name of Applicant or Parent/Guardian(Required)
MM slash DD slash YYYY
Printed name of social worker or primary doctor(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.

Jake’s Help From Heaven Technology Grant Program

Section A: Personal Information

This technology request is for(Required)
Applicant(Required)
Parent/Guardian’s Name:(Required)
Enter N/A if not applicable.
Address(Required)
Parent(s) name printed(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.

Pediatrician/primary care doctor/social worker name printed(Required)
Max. file size: 2 MB.
MM slash DD slash YYYY
This field is for validation purposes and should be left unchanged.

REPEAT JHFH APPLICANT EMERGENCY SUPPORT GRANT

This is for previously approved JHFH applicants who are experiencing an emergency situation that cannot wait until our scheduled Board of Directors meeting. Requests should not exceed $500 as funding is extremely limited. Please note that this does not replace our typical grant request program.
Applicant’s name:(Required)
Please enter a number less than or equal to 125.
Parent/Guardian’s name:(Required)
Address(Required)
Max. file size: 2 MB.

Jake’s Help From Heaven Repeat Applicant Program

Applicant:(Required)
Parent/Guardian’s Name:(Required)
Address(Required)
MM slash DD slash YYYY
Was it approved?(Required)
Parent’s name printed(Required)
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.
This field is for validation purposes and should be left unchanged.