"*" indicates required fields Step 1 of 2 50% Eligibility AssessmentAre you applying for yourself or for your child?* Self Child Is applicant a US Citizen or non-US Citizen with Lawful Immigration Status or Permanent Resident?* Yes No Is applicant under age 21?* Yes No In which county does applicant reside?* Coffey County, Kansas Lyon County, Kansas Osage County, Kansas Elsewhere Has applicant resided in the county continuously for a minimum of one year?* Yes No Your child is not eligible. Your child must be under age 21, must be a US Citizen and must currently reside in Coffey, Lyon, or Osage County Kansas and have done so continuously for no less than one year immediately prior to application. Return to Home PageYou are not eligible. You must be under age 21, must be a US Citizen and must currently reside in Coffey, Lyon, or Osage County Kansas and have done so continuously for no less than one year immediately prior to application. Return to Home PagePlease click Next to proceed to the application. Are you renewing a previously approved application?* Yes No Applicant's informationApplicant's Legal Name* First Last Applicant's last 4 digits of SSN*Applicant's Address* Street Address City AlabamaAlaskaAmerican 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 Applicant's Date of Birth*MonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920This field is hidden when viewing the formAge*Applicant's Sex* Male Female Applicant Daytime Phone*Applicant Email* Parent/Legal Guardian(s) contact information with whom applicant resides (if applicable)Parent/Legal Guardian Name:* First Last Relationship to Child*Parent/Legal Guardian Address* Street Address City AlabamaAlaskaAmerican 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 Parent/Legal Guardian Daytime Phone*Parent/Legal Guardian Email* AcknowledgementIf Jones Foundation needs to contact you, would you prefer...* Phone Email The applicant above has been diagnosed with Type 1 Diabetes, and I am requesting assistance with expenses associated with his/her treatment. I hereby give permission to the staff of the Jones Foundation to contact the parties listed in this application or attachments thereto for purposes of verification. I am acknowledging that both the Applicant and Parent/Legal Guardian (if applicable) have resided for a minimum of one year prior to application date and that residency must be maintained in Coffey, Lyon, or Osage County to remain eligible for this Jones Foundation grant.Signature*This field is hidden when viewing the formDate*
