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Get support 

 

If you are a caregiver of a child who has a complex medical condition and would like complementary care services and support at home, please complete the grant application below. Applications are considered on an ongoing basis.

Upon receipt of the fully completed application, Eliana’s Light staff will review the application with decisions being communicated within 2 weeks of submission to both the patient and referring medical professional. The child’s medical or complementary care professional must review and co-sign the application to ensure coordination between medical and complementary care.  Applications filled out by the patient or his/her caregiver alone will not be accepted. It is understood that the medical and/or complementary care professional is applying with and/or on behalf of the patient. To receive consideration, ALL SECTIONS MUST BE COMPLETED – NO EXCEPTIONS.  ALL fields are required.  The more information that is provided, the better we are able to support each patient and her/his family. Please submit the application online or by scanning/emailing it to Eliana’s Light: info@elianaslight.org.  ** The release form at the end of the application must be signed and received by Eliana’s Light before the application can be considered. **

Read more about what we mean by “complementary care” and about the support we provide.

 
 
Patient Name *
Patient Name
Preferred Phone Number of Caregiver *
Preferred Phone Number of Caregiver
Secondary Phone Number of Caregiver, If Applicable
Secondary Phone Number of Caregiver, If Applicable
Address for Child and Primary Caregiver Who Lives With Child *
Address for Child and Primary Caregiver Who Lives With Child
Mailing Address for Child and Primary Caregiver if Different from Above
Mailing Address for Child and Primary Caregiver if Different from Above
Is The Mailing Address a Secure Location For Receiving Deliveries of Gift Cards and Packages? *
This can be a grandparent, social worker, or sibling over 18 years old. Please explain the relationship of this person to the child. It is not necessary to complete this section if Eliana's Light should communicate directly with the child's primary caregiver noted above.
Check One Of The Following To Explain The Amount of Medical Insurance The Family Has.
Providing the following information is optional but strongly encouraged, as it will assist Eliana's Light in obtaining grants for specific, targeted demographics. Disclosing this information has no effect on services granted.
Check One Of The Following To Explain The Child's Race/Ethnicity.
Providing the following information is optional but strongly encouraged, as it will assist Eliana's Light in obtaining grants for specific, targeted demographics. Disclosing this information has no effect on services granted.
Check One of the Following To Explain The Marital Status of the Child's Primary Caregiver
Providing the following information is optional but strongly encouraged, as it will assist Eliana's Light in obtaining grants for specific, targeted demographics. Disclosing this information has no effect on services granted.
Check One of the Following To Explain The Child's Household Income Level
Providing the following information is optional but strongly encouraged, as it assists Eliana's Light in obtaining grants for specific, targeted demographics. Disclosing this information has no effect on services granted.
Please include the name of the specific unit(s), if applicable (e.g. Cardiac Intensive Care Unit at Children's National Medical Center).
Address of Hospital or Medical Treatment Facility *
Address of Hospital or Medical Treatment Facility
This may be a complementary care service provider (e.g. a yoga studio, an acupuncturist, etc.) or a therapist. Please provide a short explanation.
Address of Secondary Care and Treatment Facility, If Applicable
Address of Secondary Care and Treatment Facility, If Applicable
Name of Professional Making Referral *
Name of Professional Making Referral
This may be a doctor, nurse, social worker, case manager, Child Life Specialist, or therapist.
Phone Number of Professional Making Referral *
Phone Number of Professional Making Referral
Are You Comfortable Sharing Your Family's Story? *
If you check "yes", we believe you will inspire others to support Eliana's Light. Therefore, we'll be able to help other families like yours. We'll send you a short questionnaire to complete.
I Give Eliana's Light The Absolute Right and Permission To Use a Photo That I Will Provide In Which Our Family Is Pictured For The Purpose of Promoting and Marketing Eliana's Light. *
This is required if you agree to share your family's story.
I Give Eliana's Light The Absolute Right and Permission to Use My Child's Name, My Family's Name, and Approved Excerpts from Correspondences About My Family in Promotional Efforts for Eliana's Light. *
This is required if you agree to share your family's story.
Please include details of the child's and caregiver's/caregivers' financial, emotional and physical stress, as well as any relevant details pertaining to the family's home situation.
Please note whether your application was approved or denied.
Please Select Which Type(s) Of Support You Would Like To Receive From Eliana's Light *
You may select more than one. Please note that Eliana's Light is unable to provide financial assistance for rent, mortgage payments, utilities, medical co-payments, prescription payments, clothing, transportation, or child care at this time.
Please Click "Yes" Below If You Have Read, Understood and Agreed To the Downloadable Child/Family Liability Release and Privacy Protection *
Your application will only be considered if you select "yes".