FINANCIAL ASSISTANCE FOR FAMILIES

Helping Families Get Through Financial Trouble

Grants

We have helped more than 7,158 families including our first international family who had found us on the Internet. The amount of our grants are growing in proportion to the monies coming in to Aubrey’s Foundation. We are pleased to say that we are able to help more families with bigger amounts than we’ve been able to in the past.

PREPARING YOUR GRANT APPLICATION

The Trustees of the Aubrey Rose Foundation want to give your proposal the consideration it deserves. your grant application is the most important stage in the Foundation’s evaluation of your proposal. For this reason, you should address each question asked, specifically and completely.

The various steps in the application process are:
Telling us about your family, your children and their ages
Where you live
Description of your child’s situation
Objective for what you are asking for
Please send a picture of your child so that we can see who we are helping
Explanation of benefits statement and Coordination of Benefits statement (if applicable) from insurance company(s).
Attach legible copies of actual bills that you want us to pay. (Please do not send original bills - those are for your records.)

SUBMITTING YOUR APPLICATION

You may submit your application at any time during the calendar year. The Foundation’s Board of Trustees meets quarterly to review grant applications. Applicants will be notified no later than 60 days after review.

APPLICATION TIMELINES
Grants are awarded on a quarterly basis. The Foundation’s Board of Trustees meet in March, June, September and December. Applicants will be notified no later than 60 days after the Board of Trustees’ meeting.

ELIGIBILITY
The Aubrey Rose Foundation helps families with children who are currently living with a life-threatening medical condition. Grants are awarded based on need. If a family has outstanding medical bills that insurance will not cover, our Foundation can possibly help out a family in need until our annual funds have been exhausted. As our funds grow, so will the number and the amount of help we will be able to give. We appreciate families just asking for one grant per family so that we can help as many families as possible.

INELIGIBLE REQUESTS
Ineligible requests such as medical bills already paid, submitting for food, clothing, laundry fees, mortgage payments and associated homeowner bills and anything deemed non-medical for your child will not be acceptable criteria to submit a grant request.

OUR GUIDING PRINCIPLES
Our philosophy is to provide a balanced giving program that considers the total well-being of the child and how the request benefits their family also. Aubrey Rose Hollenkamp was always a very happy baby throughout everything she endured including a heart and double lung transplant. She smiled continuously throughout her short life. We would like to carry on her spirit by being able to put smiles on other children’s faces and their families. We can do this by helping to pay some medical bills that normally wouldn’t be covered.

GRANT APPLICATION

You can now either download, print and mail in the application or fill it out online (submitting all information electronically). Fill out the form below to complete the application online; or follow the directions below to download and mail the application. We prefer that you fill out the application online.

These grants are awarded on a quarterly basis. The Foundation’s Board of Trustees meets quarterly; however, you may submit your application at any time during the year. Applicants will be notified no later than 60 days after the Board of Trustees’ meeting.

Grants are awarded based on need and will go into a queue to be paid. If a family has outstanding medical bills that insurance will not cover, our Foundation can possibly help out a family in need until our annual funds have been exhausted. As our funds grow, so will the number and the amount of help we will be able to give. If our Foundation finds you eligible to have a medical expense paid for, we will send a letter to you for your records, confirming what funds were provided to which provider on your behalf. If the information is complete and we cannot help you with funds, an email will be sent to you.

FINANCIAL ASSISTANCE APPLICATION

GUIDELINES
The grant application is for families with children (Age 18 and under) who have a life-threatening medical condition. _

Today’s Date(Required)

Child's Full Name(Required)

Person Filling Out Application(Required)

Child's Date of Birth(Required)

Child’s Diagnosis(Required)

Mother's Full Name(Required)

Father's Full Name(Required)

Is this diagnosis a life-threatening medical condition(Required)

Please tell us in a concise manner about the condition of patient and prognosis.(Required)

Please tell us about your immediate family, the names of siblings and their ages. We know first-hand that it is not just the patient who is sick, but rather, it's the whole family!(Required)

Does family live at same address? (If no, please provide both addresses)(Required)

Address(Required)

Address

Telephone (Cell)(Required)

Email(Required)

Telephone (Work)(Required)

Upload a picture of your child(Required)

Accepted file types: pdf, doc, Max. file size: 20 MB.

Attach outstanding medical bills related to the applicants condition you would like to have paid. Copies of bills are acceptable as long as they are legible. Please provide an itemized page with the name of the organization to be paid, their telephone # with area code, account # of claim, date of service and amount to be paid. Bills will not be paid for without this itemized statement. Statement is below for you to fill out. Upload File(Required)

Accepted file types: pdf, doc, Max. file size: 20 MB.

If you are approved for financial assistance from the Aubrey Rose Foundation, by signing this application, you are giving the Aubrey Rose Foundation permission to publish your story if needed. Please sign your name to give the Aubrey Rose Foundation permission to talk to the organization(s) that you want help with.(Required)

give the Aubrey Rose Foundation permission to talk on my behalf regarding patient(Required)

Your Name(Required)

Date(Required)

ITEMIZED STATEMENT

Parent completing app

Child's Full Name

IN ORDER TO HAVE YOUR BILLS PAID, ALL FIELDS ON THE 1ST LINE BELOW ARE REQUIRED TO BE COMPLETED ON THIS ITEMIZED STATEMENT. ADDITIONAL BILLS CAN USE ADDITIONAL LINES TO BE FILLED OUT.

ORGANIZATION TO BE PAID(Required)

ORG. PHONE # W/AREA CODE(Required)

ACCOUNT #(Required)

DATE(S) OF SERVICE(Required)

AMOUNT TO BE PAID(Required)

TOTAL AMOUNT OF HELP YOU ARE REQUESTING: $(Required)

ORGANIZATION TO BE PAID

ORG. PHONE # W/AREA CODE

ACCOUNT #

DATE(S) OF SERVICE

AMOUNT TO BE PAID