To apply for assistance, please fill out the form below and we will be in touch shortly.

Your Name (required)

Your Email

Telephone Number

Date of Birth (required)

Social Security Number

Child's Name (required)

Child's Date of Birth (required)

Child's Social Security Number

Type of Assistance Requested: (required)

If you checked Other above, please explain:

Brief Overview of Current Circumstance:

Once you have submitted the form, please email the following to

Photo ID
Medical Diagnosis
Social Security Card
Child’s Birth Certificate
Child’s Social Security Card
Proof of Income

The above documentation is preferred but not required to be submitted with the initial application; however, this documentation is required prior to release of individual grants.