SCID Angels Family Scholarship Fund Application




First Name:
Last Name
Email Address:
Home Street Address
Home City
Home State
Home Zip Code
Is this also your mailing address? Yes
No
If no, please provide your mailing address
Home Phone Number
Mobile Phone Number
Work Phone Number
Fax Number
Other Contact Phone Number (specify location: e.g., hospital room, family member’s home, etc.)
I prefer to be contacted for follow up questions by: Email
Home Phone
Mobile Phone
Work Phone
Fax
Other Phone Listed Above
Your SCID Angels Family Scholarship Fund Request
Do you have a child with a SCID diagnosis? Yes
No
What is the child’s sex Male
Female
Child’s first and last name
Amount of Request (Not to exceed $1,000 per calendar year).
Do you need assistance with any of the following: Child Care For Sibling
Food/Nutrition
Medical Expenses
Rent Assistance
Utilities
Medical Equipment
Other
If you selected “Other”, please specify
Describe the need and use of funds (please describe what the funds are to be used for, reason needed, and how this will improve the quality of life for your SCID affected child in the box provided)
SCID Angels for Life has limited scholarships available and cannot fund all requests. Tell us what makes you the ideal candidate for this funding?
Other Funding Sources
Is your child eligible for insurance? Yes
No
Uncertain
Is your child currently covered by private insurance? Yes
No
Uncertain
Does your child have Medicaid/SSI? Yes
No
No, but we are applying
Unsure
Diagnosis Details
Do you have more than one child diagnosed with SCID? Yes
No
Another child is being tested
What is your child’s form of SCID? (example, X-Linked, ADA, Jak3, unknown, etc.)
Was your child diagnosed through newborn screening? Yes
No
If diagnosed through newborn screening in what state?
At what age was your child diagnosed?
Is your child currently hospitalized? Yes
No
At home in isolation, but awaiting treatment in the hospital
Are you working with a Social Worker Yes
No
If you are working with a Social Worker, may we contact him or her? Yes
No
If we may contact your Social Worker, please provide his or her name and contact information.
Who is your child’s Immunologist? If you are not being seen by an immunologist, who is your treating physician and what is their area of specialty (e.g., Hematologist/Oncologist, Pediatrician, General Practitioner)?
By checking the box below, I understand all information will be used for Scholarship Evaluation and I affirm all information provided is accurate to the best of my knowledge. I agree
By checking the below box, I understand that if provided a scholarship, I will be responsible for any applicable state or federal taxes which may apply. I agree