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Application details
This application will take about 15 minutes to complete. You cannot save your work once you start. Please complete all sections truthfully. If information is found to be misleading, false, or inaccurate, the application will be disqualified.
Items needed to complete the application:
- Dates of last and next appointments
- Copies of utility, rent and/or mortgage statements. (Copies of actual bills or statements are required.)
- A copy of your lease (if renting)
- Verification of income, diagnosis and treatment
Remittance documents must be legible and include all of the following or they will not be accepted: Full account number, name and address of applicant, company and mailing address, amount due. If you don't have copies handy, we will reach out to you to complete your submission.
All incomplete applications or applications with missing documentation will be returned. Payment for all the above is made directly to the provider, not the patient or family.
Documents may be uploaded using this form or faxed to our office at 330.835.5978.
If you would like to see the complete application or apply by mail, CLICK HERE.
FAQs
Do your services cost anything?
Thanks to the generous support of our dedicated donors, and our longstanding community relations, we are pleased to provide programs and services at no cost to our applicants and participants.
Where are you located?
We are based in Akron, Ohio (Summit County) but our grant giving and programming reach into Medina, Portage, Stark and Wayne counties.