APPLICATION FOR ASSISTANCE

Please be advised that all financial and personal medical information contained in this application will remain confidential.

Dear applicant,

The Ricky King Children's Fund exists solely for the purpose of providing specific medical needs for children in Lee, Collier, and Charlotte Counties not met by insurance companies or governmental agencies.

Candidates are usually referred by other charitable organizations in Southwest Florida. Once a candidate is identified, an application is sent to the family.

Mr. Don Berry, Mrs. Linda Cardillo, and Mrs. Debbie Cook reviewing an application.

When the application is returned to the Grant Coordinator copies are mailed to the Grant Committee. This usually occurs within two days of receipt. These members get back to the Grant Coordinator usually within a week of receipt of the application.

Usually, the committee agrees if all criteria are met. If they are not in agreement they discuss other alternatives and the Grant Coordinator gets back with the family.

Once an agreement has been made on the amount of assistance, a check is made out to the supplier of the medical equipment. Normal purchases would include wheelchairs, wheelchair ramps, van conversions for wheelchairs, and breathing apparatus.

Participation is usually limited to approximately $8,000.00 per application, although this is up to review by the committee for every case. When a challenging case is before the committee it is not unusual to go to the full board for approval.

A case with no conflicts can ideally be processed within a few weeks.

If you have any questions about this application or our grant review process, please contact The Ricky King Children's Fund office at 239-262-1808.

Sincerely,

Jennifer Weidenbruch
Executive Director

Please complete this needs assessment form to the best of your ability. The Ricky King Children's Fund primarily funds medical equipment costs which are not covered by other social service agencies or insurance companies. If approved, payment will be made directly to the vendor providing the equipment or service. The Ricky King Children's Fund does not pay for hospital bills.

Applicant's full name:
Child's full legal name:
Age:
Diagnosis:
Your relationship to child:
Additional legal guardian:
Applicant's address:
Telephone #:
Email:

Which organization should we thank for referring you to us?

Name:
Address:
Town:
Zip:
Telephone:
1. What are you requesting from The Ricky King Children's Fund? Please mail complete medical verification from your physician, including physician name, address, and telephone number to: The Ricky King Children's Fund, 5051 Castello Drive, Suite 21, Naples, Florida 34103.
2. What is the dollar amount of your request?
3. What other social services or sources of financial assistance have you contacted regarding this particular request?
4. What county do you live in?
5. How long have you lived in this county?
6. Your address prior to this county.
7. Do you have a valid Florida drivers license? Yes No
8. What is your license number?
9. What language(s) do you speak?
10. Do you qualify for Medicaid? Yes No
11. Does your employer offer health insurance? Yes No
12. Do you participate in your company's health plan? Yes No
13. If there is additional information that you would wish to furnish, or feel The Ricky King Children's Fund should be aware of, please provide in this space.

MEDICAL RELEASE AUTHORIZATION:

Physician' Name:
Physician's Address:
Physician's Phone #:

I authorize the aforementioned attending physician to release to The Ricky King Children's Fund, medical information and the records pertaining to my child.

Child's Full Legal Name:
Applicant's Name:
Date:

FINANCIAL INFORMATION

Marital Status:
 Married Single Divorced Widowed
Number of dependents in your household:

Monthly Income:

Name and address of current employer:
Employer's Telephone:
Applicant's Wages:
Additional legal guardian's name and address of employer:
Telephone:
Guardian's Wages:
Child Support:
Alimony:
Food Stamps:
Other Income:
Total Income:
Other types of financial assistance:

Monthly Expenses:

Rent/Mortgage:
Food :
Electric:
Telephone:
Water:
Gas:
Household Repairs:
Car Payment:
Car Insurance:
Clothing:
Medical Insurance:
Medical Supplies:
Recreation:
Miscellaneous:
Total Expenses:

List of creditors:

Name:
Name:
Name:
Name:
Total Amount Owed:

All financial information will remain confidential.

PUBLIC RELATIONS RELEASE AUTHORIZATION

The Ricky King Children's Fund refers to the children that we help as "King's Kids" in all of our media material. We ask your permission to use only your child's first name, how the fund helped, and a recent photograph in all of our public relations materials in order to increase public awareness of The Ricky King Children's Fund. We also ask that you write a personal thank you letter to the fund to be used for publicity purposes.

 Yes, I give my permission to use only the first name, how the fund helped, and a recent photo of my child for publicity purposes to The Ricky King Children's Fund.
No, I prefer not to have my child's photo used in your public relations material.

YOUR LETTER TO BE USED FOR PUBLIC RELATIONS IF APPROVED FOR FUNDING.

The Ricky King Children's Fund AND/OR THE RICKY KING FOUNDATION MISSION STATEMENT - The mission of The Ricky King Children's Fund is to provide a conduit of community support from individuals, corporations and organizations for the unmet medical needs of children and youth in Collier, Lee, and Charlotte Counties. The Fund provides financial support and information resources for medical needs, and strives to maintain the dignity of every individual. The Ricky King Children's Fund and/or The Ricky King Foundation is a 501(c)(3) organization. Tax I.D. #59-3574310