Medical Grant Online Application

"*" indicates required fields

Step 1 of 6

Application for Assistance
Referred by:
Is this your first time applying?*

Yes

No
If yes, how did you hear about us?*
Child's Information for whom you are applying.
Click the plus sign at the right of the line below to add additional children, if needed.*
First Name
Middle Name
Last Name
Age
Date of Birth
Gender
Last 4 digits SSN

This field is hidden when viewing the form
Ages of children-hidden field used for signature
Number of years Child has resided in Coffey, Lyon or Osage County:*
General Medical Information
What medical treatment was received or needed? Please provide DETAILED information.*
Medical Provider (click the plus sign to list as many providers as needed):*
Medical Provider Name
Date of Medical Services:

Does Child have medical insurance?*

Yes

No
If yes, Insurance Name:*
Dental Information
What dental treatment was received or needed?*
Dental Provider (click the plus sign to list as many providers as needed):*
Dental Provider Name
Date of Dental Services:

Orthodontics Information
Orthodontist's Name*
Date of First Visit*
Dental Insurance
Does Child have dental insurance?*

Yes

No
If yes, Insurance Name:
Vision Information
Eye Doctor's Name*
Eye Doctor's Location*
Business Name & Location where you will purchase glasses?*
Does Child have vision insurance?*

Yes

No
If yes, Insurance Name:
Does vision insurance cover eye exams?*

Yes

No
Does vision insurance cover glasses?*

Yes

No

Parent/Legal Guardian Household Information:
Parent/Legal Guardian Marital Status*
Custodial Parent Name*
First Last
Relationship to Child*

Self

Mother

Father

Legal Guardian
Custodial Parent Address*
Street Address City State ZIP

Custodial Parent Employer*
# of Years*

Less than one year

One year or more
Hourly Wage*
Hours per week*
Pay Frequency*
Contact name for household information questions*
Phone # between 8:30 AM to 5:00 PM*
Email*

Including the child for which you are applying, how many children live in your home? DO NOT include yourself and your spouse/partner in this total.*
Spouse/Partner Information
Spouse/Partner Name*
First Last
Spouse/Partner Employer*
# of Years*

Less than one year

One year or more
Hourly Wage*
Hours per week*
Pay Frequency*

If you do not file taxes, what is your reason?
If the Child for which you are applying is NOT listed as a dependent on your tax return, who claimed & why?
If household income is expected to be less than previous year, provide specific explanation below:
Additional Income
If you or anyone in your household currently receives any of the additional income below, enter monthly amount received and provide proof.
Cash Assistance (if none, type $0.00):*
Child Support (if none, type $0.00):*
Death Benefits (if none, type $0.00):*
Disability (if none, type $0.00):*
Food Stamps (if none, type $0.00):*
Military (if none, type $0.00):*
Retirement (if none, type $0.00):*
SSI (if none, type $0.00):*
Unemployment (if none, type $0.00):*
Do you own, are purchasing, or rent your home? (check all that apply)
Own or purchasing a home
Rent a home or apartment
Rent a lot for a mobile/manufactured home
None of the above
If own or purchasing, what is appraised value of home & acreage?*
Amount of acreage included (if any)
Current payoff amount of mortgage*
If renting, amount paid per month*
First and Last Name of Individual or Company Name to whom rent is paid*
If none of the above, please explain*
Do you own or purchasing a vehicle or vehicles of any kind, including but not limited to, cars, trucks, SUVS, vans, RVs, motorcycles or watercraft?

Yes

No
Itemize below ALL vehicles (even if amount owed is $0.00) including, but not limited to, motorcycles, RVs, and watercraft. (Click the plus sign to the right of each line to add as many vehicles as needed.)*
Year
Make/Model
Payoff amt

If no vehicles are owned, please explain:
Additional Assets
Itemize below all Additional Assets. This includes, but is not limited to, ALL savings, retirement and college savings plans, investment accounts, rental property, additional land, business property and equipment, farm equipment, livestock, crops, etc... List all property by physical address. (Click the plus sign to the right of each line to add as many assets as needed.)
List of Accounts
Click the the plus sign to the right of the line below to add more accounts.
Savings, Retirement, & College Savings Plans, Investments Accounts, etc...
Market Value
Loan

List of Property
Click the the plus sign to the right of the line below to add more property.
Rental Property, Business Property & Equipment, Farm Equipment, Livestock, Crops, etc...
Market Value
Loan

Debts
In 'Debts', provide the total payoff balances for any additional bills you owe other than what is previously listed.
Total of All Medical/Dental Bills (if none, type $0.00):*
Total of All Credit Cards (if none, type $0.00):*
Total of Other Outstanding Loans not listed in application (if none, type $0.00):*

Acknowledgement
By completing this form and signing below, I acknowledge and agree to the following statements:

This form is an application only. Completing this form does NOT guarantee the receipt of a Jones Foundation medical grant.

The Jones Foundation reviews each application to determine whether the qualifications and eligibility for financial assistance have been met. The Foundation's Board of Trustees , in its sole discretion, has the final decision regarding the qualification, eligibility, and the amount of financial assistance to be awarded.

All information provided in this application and its supporting documentation is true and accurate to the best of my knowledge and belief. I am providing this information voluntarily.

I understand that intentional misstatements or falsification of the information in the application will render me immediately ineligible for the Jones Foundation medical grant.

I certify that each child named in this application (i) is a United States citizen, (ii) is under the age of 21, (iii) resides in Coffey, Lyon, or Osage County and (iv) has continuously resided in Coffey, Lyon, or Osage County for no less than one year immediately prior to the date on this application. I will immediately inform the Jones Foundation if this information changes in any way.

I understand that I must maintain residency in Coffey, Lyon, or Osage County to maintain eligibility for a Jones Foundation medical grant. I understand that failure to maintain residency in these counties may result in the immediate loss of the Jones Foundation medical grant, if awarded.

All information provided in this application and its supporting documentation may be reviewed by the Jones Foundation staff and its Board of Trustees. I authorize the review of the information provided herein, including any protected health information, by the Jones Foundation staff and its Board of Trustees to determine eligibility for the medical grant. I authorize the Jones Foundation staff to contact those certain providers named in this application to verify or supplement the information provided in the application or supporting documentation.

Restrictions on Use or Disclosure of Information
I request that the Jones Foundation NOT release to or discuss the information provided herein or attached with the following individuals:
Name
Relationship

Electronic Signature
Applicant Father's Signature*
Use your computer mouse or your finger (if using a smart phone or tablet) to draw your signature below:
Applicant Mother's Signature*
Use your computer mouse or your finger (if using a smart phone or tablet) to draw your signature below:
Applicant Legal Guardian's Signature*
Use your computer mouse or your finger (if using a smart phone or tablet) to draw your signature below:
Applicant Signature - Required if Applicant is over the age of 18 as of the date of this Application.*
Use your computer mouse or your finger (if using a smart phone or tablet) to draw your signature below:
Date

*
I understand that checking this box constitutes a legal signature confirming that I acknowledge and warrant the truthfulness of the information provided in this document.

Your child is not eligible.

Please click Next to proceed to the application.

There are additional eligibility requirements for braces. You'll be asked some additional questions about braces on the next screen.

Your child is not eligible for braces

Your child IS NOT eligible for braces, but IS ELIGIBLE for other medical or dental assistance.

Please click Next to proceed to the application.

Child's Information for whom you are applying.

General Medical Information

Dental Information

Orthodontics Information

Dental Insurance

Vision Information

Parent/Legal Guardian Household Information:

Spouse/Partner Information

Additional Income

Additional Assets

Debts

Acknowledgement

Restrictions on Use or Disclosure of Information

Electronic Signature