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Apply For Help

Apply For Help

Financial assistance may be available if your child is currently inpatient due to a cardiac crisis at Children’s National Medical Center in Washington, DC.

Please download a printable version of our Apply For Help form.

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• Date*
  MM slash DD slash YYYY
• Applicant's Name*
• Relationship to Child*
  Relationship to Child *MotherFatherGrandparentLegal GuardianOther
• Applicant's DOB
  MM slash DD slash YYYY
• Address*
  Street Address City State / Province / Region ZIP / Postal Code
• Email
• Home Phone
• Cell Phone*
• Religion
• Child's Name*
• Child's DOB*
  MM slash DD slash YYYY
• Gender
• Child's Cardiac Diagnosis
• Year of Diagnosis
• Medical Center*
• Name of Social Worker*

• Please explain how your child's heart-related medical problems are impacting you and why you are seeking financial assistance at this time.

• Letter of Hardship*
  Click below to fill out…
• Need Assistance with: **
  • lodging expenses
  • meal expenses
  • transportation cost
  • co-pays
  • mortgage /rent pmt
  • utility payments
  • other
• Specify lodging expenses:
  Click below to fill out…
• Specify meal expenses:
  Click below to fill out…
• Specify transportation expenses:
  Click below to fill out…
• Specify co-pay expenses:
  Click below to fill out…
• Specify mortgage/rent expenses:
  Click below to fill out…
• Specify utility expenses:
  Click below to fill out…
• Other:
  Click below to fill out…

• Please submit documentation of expenses for which you would like to receive assistance with. You may upload your receipts, invoices, statements, or quotes here:

• invoice or statement 1
  Max. file size: 8 MB.
• invoice or statement 2
  Max. file size: 8 MB.
• invoice or statement 3
  Max. file size: 8 MB.

• We are aware that your journey is extremely difficult, and we want you to know we care. Our care team exists to listen, encourage and pray for you during your crisis. Although we often provide financial support, Wholehearted Foundation’s hope is to also provide you with emotional and spiritual care.

• Would you like to be contacted by a member of our Care Team?
  • yes, I would like that
  • no, not at this time
• Wholehearted Foundation Team Members may contact me to offer care (may include conversation, prayer, whatever is helpful) in the following ways (check all that apply):
  • phone
  • email
  • mail

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