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
Is this your first request for financial assistance from SCID Angels?	Yes No
Child's first and last name
Amount of Request (Not to exceed $1,000).
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
At what hospital are you currently being treated at?
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
At this time, SCID Angels can only award Family Scholarship requests to first time applicants.