Application for Special Project

To be considered for a special project, you must submit this application and agree to an in-person interview in your home. (Fundraising will include a personal video of you and your child telling your story which will be posted on THE SHINE FOUNDATION social media). Applications will be reviewed and are chosen at the complete discretion of THE SHINE FOUNDATION board members.

Child's Name

First Last

Date of Birth

Diagnosis

Parent's Name

First Last

Phone

Address

Street Address City State ZIP Code

Assistance Requested

(Please be as specific as possible on what and why.)

References

Please provide the name and phone of at least three (3).

Close Friend Name

First Last

Close Friend Phone

Teacher Name

First Last

Teacher Phone

Therapist Name

First Last

Therapist Phone

Pastor/Sunday School Teacher Name

First Last

Pastor/Sunday School Teacher Phone

Family Member Name

First Last

Family Member Phone

Physician Name

First Last

Physician Phone

Tell us about your child

Hardship Form

Applicant Name

First Last

Date of Birth

Responsible Party

First Last

Relationship

Phone

Employer

If unemployed, date last worked

Are you currently receiving government assistance?

Yes

Agency?

Total Number of Dependents in Household

Responsible Party Monthly Gross Income

Spouse Monthly Gross Income

Other Monthly Income

Pension

Public Assistance

VA Assistance

Child Support

Unemployment

Alimony

Workers Comp

Signature

Date

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Comments

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