First Name Parent/Guardian (1)
Last Name Parent/Guardian (1)
Job Title (1)
First Name Parent/Guardian (2)
Last Name Parent/Guardian (2)
Job Title (2)
Primary Phone Number
Secondary Phone Number
Primary Email
Secondary Email
Street Address
City
State/Region
Zip/Postal Code
Country United States Canada Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Brazil British Indian Ocean Territory British Virgin Islands Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Croatia Cuba Curaçao Cyprus Czech Republic Côte d’Ivoire Democratic Republic of the Congo Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Honduras Hong Kong S.A.R., China Hungary Iceland India Indonesia Iran Iraq Ireland Isle of Man Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macao S.A.R., China Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Korea Northern Mariana Islands Norway Oman Pakistan Palau Palestinian Territory Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Romania Russia Rwanda Réunion Saint Barthélemy Saint Helena Saint Kitts and Nevis Saint Lucia Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Korea South Sudan Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Timor-Leste Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu U.S. Virgin Islands Uganda Ukraine United Arab Emirates United Kingdom United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Vatican Venezuela Viet Nam Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe
Are you and/or your spouse a citizen(s) of the United States? YesNo
Total Number of Dependent Children
Total Number of Children Adopted
Church Name
Church Web Address
Pastoral Reference Full Name
Pastoral Reference Email
Pastoral Reference Phone Number
Church Street
Church City
Church State
Church Zip Code
Parent 1 understanding of the gospel
Parent 2 understanding of the gospel If the child has one Parent/Guardian, please note above.
Statement of Faith Response I/We have read and agree with Show Hope's Statement of FaithI/We have read and do not agree with Show Hope's Statement of Faith
First Name
Middle Name
Last Name
Gender MaleFemale
Child's Date of Birth
Child's Adoption Finalization Date
Country of Birth United States Canada Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Brazil British Indian Ocean Territory British Virgin Islands Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Croatia Cuba Curaçao Cyprus Czech Republic Côte d’Ivoire Democratic Republic of the Congo Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Honduras Hong Kong S.A.R., China Hungary Iceland India Indonesia Iran Iraq Ireland Isle of Man Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macao S.A.R., China Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Korea Northern Mariana Islands Norway Oman Pakistan Palau Palestinian Territory Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Romania Russia Rwanda Réunion Saint Barthélemy Saint Helena Saint Kitts and Nevis Saint Lucia Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Korea South Sudan Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Timor-Leste Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu U.S. Virgin Islands Uganda Ukraine United Arab Emirates United Kingdom United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Vatican Venezuela Viet Nam Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe
Name of Adoption Agency at time of Placement
Name of Insurance Provider
Name of Policyholder
Family Deductible
Family Deductible Met Dollar amount at time of application
Individual Deductible
Individual Deductible Met for Child Dollar amount at time of application
Out-of-Pocket Maximum per Individual
Out-of-Pocket Met for Child Dollar amount at time of application
Insurance Type Private/Employer-providedMedicaidTricarePrivate share-cost planOther
Name of Policyholder (Secondary)
Name of Provider (Secondary)
Family Deductible (Secondary)
Individual Deductible (Secondary)
Out-of-pocket Maximum per Individual (Secondary)
Secondary Insurance Type MedicaidTricarePrivate share-cost planOther
Please explain any "Other" selections, additional coverage, or financial assistance as it relates to your child's medical expenses.
Provider's Full Name
Provider's Credentials
Group Affiliation Name
Website Address
Provider Phone Number
Street Mailing Address
City, State, Zip Code
Briefly describe your child's medical diagnosis and/or needs.
For which of the following medical services are you applying to receive grant funding for? Surgical Procedure(s)Rehabilitative Physical TherapyRehabilitative Occupational TherapyAssistive Device or Equipment
List the total estimated out-of-pocket expenses the applicant has incurred or will incur from the above medical services. Eligible expenses considered can be incurred up to 12 months prior to or past the application date.
List the date of service your child received care. If care was received over multiple dates, please provide the exact date range. i.e 3/1/2020 or March 1–5, 2020
Please provide a summary explanation for the medical services/equipment received or anticipated.
Beyond your child's physical/medical needs, describe any steps you have taken/plan to take to meet the emotional, mental, and spiritual needs of your child while they are undergoing medical care.
Additional comments on medical care needed for your child.
Describe your family's current financial circumstances and need for financial assistance for your child's medical expenses.
Combined Adjusted Gross Income (AGI) for Current Year
Combined Adjusted Gross Income (AGI) for Previous Year
Additional Financial Information Comments
Total Liquid Assets Include assets like current cash, checking & savings, Money Market Accounts, stocks & savings bonds, and resale value of durable goods (vehicles, furniture, jewelry, etc.)
Total Investments (Present Market Value) Include retirement plans (401(k), 403(b), 457), pension plans, IRAs, mutual funds, bonds, annuities, and other investments.
Real Property (Present Value) Include primary home, other homes, and other real property if owned.
Do you rent the home in which you currently live? Yes No
Family Total Debt Owed Include medical debts; home, car, and land loans; investment & business debt; credit card balances, personal loans, unpaid bills; income & property tax owed
Family Total Net Worth Sum of liquid, investments, and property assets minus total debt.
If there is additional financial information or explanation you would like to provide, please do so in the space below. Optional response.
I/We, as the Parent(s)/Guardian(s) of the child for which this Medical Care Grant application is intended, have read and agreed to the above information.
As the Parent(s)/Guardian(s) of the child for which this Medical Care Grant application is intended, I/we have read and agreed to the above information.
By checking this box and typing your name(s) below, the Parent(s)/Guardian(s) are electronically signing this application.
Parent (1) First and Last Name
Parent (2) First and Last Name Type "N/A" if child has one parent.
Date of Application Completion
Comments