Children's Charity Fund, Inc.
A 501(c) (3) tax-exempt, non-profit organization
Online Grant Application
Fill out this form online
Children's Charity Fund, Inc.
National Headquarters, Grant Dept
6623 Superior Ave Ste B
Sarasota, FL 34231
Grant Application for Medical Equipment or Education
In addition to the form we request the following:
- A letter from the child's Physician stating his/her disability.
- A prescription from the child's Physician on the equipment.
- A denial from your Insurance Co, Medicaid or Medicare.
- Most recent tax return.
- Child's photo (color)
- Child's Birth Certificate (copy)
- All questions MUST be answered.
- Request form must be notarized; fax applications will not be accepted.
Release and Statement of Confidentiality
Please Read Carefully
In consideration for the receipt of any Medical Equipment that the Children's Charity Fund, Inc. may provide to the applicant herein, applicant agrees to release the Children's Charity Fund, Inc. and hold it harmless from any loss, liability, damage, cost or expense arising out of any claim or suits which may be brought or made which in any manner relates to the equipment provided to the applicant as a result of this application.
The Children's Charity Fund, Inc. agrees to keep confidential all information, records, data and files of any nature provided to it as a result of applicant's request for medical equipment. Tho Children's Charity Fund, Inc. agrees not to disclose any such written consent from the application herein, except when and if the Children's Charity Fund, Inc. is required by a Court of competent jurisdiction to release such information.
I hereby give permission to CCF to use and permit others to use the name and likeness of applicant (child) and other biographical information pertaining to the applicant in order to promote the charitable purpose of CCF in whatever manner the Board of Directors deem appropriate. Such authorization shall include but not limited to use in CCF web site, public awareness campaign, advertisement, and solicitation to the public.
Mother's Signature ________________________________ Date ________________
Father's Signature _________________________________ Date _______________
Notary
On ________________, the above named person(s) appeared before me personally with proper ID and I hereby Notarize the signatures.
Notary Signature_________________________________ Commission expires on________________
Print This Application and mail to:
Children's Charity Fund, Inc.
National Headquarters, Grant Dept
6623 Superior Ave Ste B
Sarasota, Fl 34231