Step 1 of 6 16% AcknowledgementMakena’s Ray of Hope, Inc. (MRoH) is a 501(c)(3) non-profit public benefit corporation whose primary purpose is to provide charitable funding and assistance in obtaining integrative treatment or equipment not otherwise covered by insurance to individuals or families suffering from a catastrophic injury or illness.Prior to submitting an Application for assistance from Makena’s Ray of Hope, Inc., please first consider whether or not your Application aligns with the approved Mission Statement of Makena’s Ray of Hope, Inc., which may be found online at: https://wordpress-694160-3575500.cloudwaysapps.com Applications are kept confidential. Please note that Makena’s Ray of Hope, Inc. cannot satisfy every Application, and that Applications may be prioritized on the basis of need and available resources. Applicants may be asked to give written permission to share this information with a third-party should MRoH find it necessary in order to fully evaluate your application. MRoH will fully disclose what information will be shared, with whom the information will be shared, and why, and will obtaining written permission prior to sharing the information. Financial assistance is only available to residents of the State of California. Please note if fully approved for a grant, all payments will be made directly to the treating doctor, facility or durable medical equipment provider.By checking this box, I acknowledge that I have read, understand and agree to the above statements* By checking this box, I acknowledge that I have read, understand and agree to the above statements Injured/Afflicted PersonThis section requests information about the person who has been afflicted with a covered injury or illness. Again, all information is kept strictly confidential.* First Last * Street Address Address Line 2 City StateAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email Address* Enter Email Confirm Email Date of Birth* MM slash DD slash YYYY Gender*GenderMaleFemaleDiagnosis* Date of Diagnosis* MM slash DD slash YYYY http:// Personal Websitehttp:// Social Media Support Website Person completing this applicationThis section asks for information about the person who is completing this application.* First Last * Street Address Address Line 2 City StateAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code * Enter Email Confirm Email Phone Number*Are you over 18?*Are you over 18?I am 18 years old or aboveI am younger than 18 years oldDoes Applicant live with you?*Does Applicant live with you?Applicant lives with meApplicant does not live with meHow did you hear about us?*How did you hear about us?Google SearchOther Organization ReferralWebsitePersonal ReferralOtherPlease give us more detail - Who, Where, etc.* Assistance being soughtPlease provide us with information about the assistance you are seeking.NOTE: Some of the fields in this section ask for the uploading of files. You may upload as many files as you need for each question.Please describe in detail the specific assistance being sought by this Application. For example, please describe in detail the treatment, care, and/or advocacy being sought that is not otherwise covered by insurance.*Is the assistance you are seeking covered by insurance?*Is the assistance you are seeking covered by insurance?It is covered by insuranceIt is not covered by insuranceHave you attempted to have this assistance covered by insurance?*Have you attempted to have this assistance covered by insurance?Attempts made - Partial insurance coverage obtained.Attempts made - No Coverage GrantedAttempts have not been madeFile* Drop files here or Select files Max. file size: 450 MB. Please provide a copy of all documentation concerning your attempt(s) to seek insurance coverage for the assistance sought by this Application. Make certain to include any letters or Explanation of Benefit documents stating that you were denied coverage.Please state the names of each person living with the Applicant. GROSS monthly household income of Applicant, including all who live with the applicant.* If the Applicant receives any other assistance, please list all such agencies, foundations, and/or nonprofits, and the nature of the assistance from each one.If there is any private fundraising being done on behalf of the Applicant, please list the fundraising details. Supporting DocumentationPlease attach the following written/copied documentation with your application in order to be considered. Please note, if your application is incomplete, you will not be considered until all information is received and fully processed for presentation to the Board of Directors. You may upload as many documents as needed to for each question.File* Drop files here or Select files Max. file size: 450 MB. Please provide a copy of a letter from the treating physician and/or social worker on his/her letterhead stating the details of the unexpected or catastrophic injury or illness being suffered by the Applicant.File* Drop files here or Select files Max. file size: 450 MB. A clear original photo of either the Applicant alone, or If the Applicant is a minor, a photo of the Applicant with a parent/guardian. All Applicants are asked to sign a release ( contained in following section) which gives Makena's Ray of Hope, Inc. permission to publish the photo and a brief case history in its written materials and on its website.File* Drop files here or Select files Max. file size: 450 MB. For all persons living with the Applicant, please provide the most recent pay stub and a complete copy of the previous calendar year's tax returnFile* Drop files here or Select files Max. file size: 450 MB. Please include patient invoices, medical treatment plans, cost estimates for therapy or equipment for which you are seeking assistance. CertificationBy signing below, you declare, accept, and acknowledge the following:This Application cannot be processed until all required information requested in this Application is completed and submitted to Makena’s Ray of Hope, Inc. Any intentional misrepresentation herein will result in the loss of current and future assistance from Makena’s Ray of Hope, Inc., and may result in civil or criminal liability.If you are not the Applicant, you declare that you have the legal right to act on behalf of the Applicant for the purposes of completing and submitting this Application.The Applicant and the undersigned, if different, hereby release Makena’s Ray of Hope, Inc. from any and all liability arising from the submission of this Application; including, without limitation, the sharing of this information with third parties, as defined herein.You hereby provide your release to Makena's Ray of Hope, Inc. the rights to utilize the photo(s) attached hereto for use in written material(s) as well as on website(s) controlled by Makena's Ray of Hope, Inc. or others with whom Makena's Ray of Hope, Inc. may contract for marketing purposes.The undersigned has read all of the information provided in this Application, including all attachments and supporting documentation, and hereby certifies that all of said information, attachments and supporting documentation are true and correct as of the date set forth below.By entering your name in the field marked "Electronic Signature" and submitting this application you are effectively "signing" the Application just as you would if it were a printed document and you were affixing your written signature to it, and you agree to all the rights and responsibilities therein.Completed on this date* MM slash DD slash YYYY Application Completed On This DateEnter your complete name* Electronic SignatureCommentsThis field is for validation purposes and should be left unchanged.
