Application_for_Assistance

Gentle-Interventions.org

A child advocacy group for Mitochondrial Disorder

Gentle-interventions Application for Assistance

Gentle-interventions Application for Assistance
Childs Full Name_______________________________________________
Childs nickname__________________School Grade Level_____________
Childs DOB____________________________
Home Address_________________________________________________
City______________________State_________________Zipcode________
Mothers Name_________________________________________________
Mothers contact number__________________________________________
Mothers e-mail address__________________________________________
Mothers Occupation_____________________________________________
Fathers Name__________________________________________________
Fathers contact Number__________________________________________
Fathers e-mail address___________________________________________
Fathers Occupation______________________________________________
Father Employer________________________________________________
Childs Diagnosis_______________________________________________
When Diagnosis given___________________________________________
Primary Care Physician__________________________________________
How has your child been effected by Mitochondrial Disorder

______________________________________________________________

___________________________________________________________
Pg 2
_______________________________________________________________

_________________________________________________________
Continuation of effects
______________________________________________________________

______________________________________________________________

_______________________________________________________

What are your child’s favorite colors or most favorite characters?

______________________________________________________________

__________________________________________________________
1st Siblings name_______________________________________________
1st Siblings DOB_____________________Age_______________________
2nd Siblings name_______________________________________________
2nd Siblings DOB_____________________Age_______________________
3rd Siblings Name_______________________________________________
3rd Siblings DOB______________________Age______________________
Additional Siblings: ad attachment
How has this disorder affected your household?
______________________________________________________________

______________________________________________________________

_______________________________________________________________

_____________________________________________________
Pg 3
What are your immediate needs:

___________________________________________________________

________________________________________________________________

_________________________________________________________________

_____________________________________

What Group or Organizations have you applied to for assistance in the past 5 years

______________________________________________________________

__________________________________________________________________

______________________________________________

If so what assistance did you receive from each __________________________________________________________________

__________________________________________________________________

___________________________________________________

Use back side or add attachment if necessary.

Gentle-Interventions have rules that apply at any function you attend;
1) We do not allow financial issues, fundraising or discussions of fundraising from any group or person. If you encounter this at one of our functions, please let us know right away. If you have fundraisers you would like to discuss we are more than happy to sit down with you and talk about them, away from our functions. ALL our functions are family orientated and intended to be a “Stress Free” environment for the children to just be children.
2) All our functions are child friendly and a child type meal is served, if your child needs special food please let us know in advance of the function and we will do everything in our power to make sure it is taken care of. The only exception to this is the Thanksgiving meal which is a sit down served meal to your family.
Pg 4
3) We do not allow Parents to compare children’s issues with other parents, due to Mitochondrial Disorder’s wide range of effects on each individual child, no two children’s symptoms will be the same and discussing them will just cause stress.
By submitting this application for assistance to Gentle-interventions, you agree to full disclosure of financial needs, income verification, in home visit or other investigative procedures of Gentle-interventions.org, it’s officers and or investigators. If found to be un-truthful in any answers or failure to comply with request for information or home visitation or if found to have alcohol or tobacco products or other non essential items in the home, it is understood that Gentle-interventions will sever all ties and obligations.
Signed______________________________________________
Date___________/__________/____________
Mail to; Gentle-interventions.org, P.O. Box 907972, Gainesville Ga. 30501

Gentle-interventions.org

P.O. Box 907792

Gainesville, Ga. 30501

Contact information:

Dan or Donna Dacus

678-943-5340

(Please leave a message, we will return your call as soon as possible)