STRIPE PROGRAM

Is this financial assistance request for someone living with or directly impacted by Edwards Syndrome, Trisomy 18?(required)

If NO, stop here. Submit your request using our CONTACT US form here. If YES, continue below.

How did you hear about us?

Email Address (please provide an email address you check regularly)(required)

Mother's First and Last Name (required)

Father's First and Last Name (required)

Home Address (Street Number) (required)

City, State, Zip/Postal Code (required)

Telephone Number(required)

Is Mother employed?(required)

Is Father employed?(required)

Family Size (include parents and all dependent children <19 years old who reside at the above address)(required)

Person completing this form?(required)

If other, list your first and last name

If other, what is your relationship to the family listed on this form?

If you are a healthcare professional, practitioner, counselor, social worker, or any other related professional, please list the hospital and/or organization you represent along with the address, city, state, zip/postal code. Please also include your telephone number and email address in the event we need to contact you.

Name of the child with Edwards Syndrome, Trisomy 18(required)

Date of Birth or Expected Arrival Date(required)

Date of Death (if applicable)

Additional Medical Diagnoses, if any

My child has:

Child's Race: (required)

Child's Ethnicity: (required)

Child's Gender: (required)

Do you have health insurance through an employer or the Health Insurance Market Place?

Do you have secondary insurance through a spouse or partner?

Do you have Medicaid or Children's Health Inusurance Program (CHIP)?

What type of financial assistance are you requesting? Check all that apply(required) Mortgage, housing, or rental

Utility

Car payment

Medical travel, including mileage, fuel/gas assistance, lodging, meals

Durable medical equipment

Out-of-pocket medical expenses, non-covered services or supplies

Extended inpatient hospital stay

Nutrition assistance, including formula orgroceries

Something else

How much financial assistance are you requesting?(required)

Please use this space to provide more details about your request.(required)

Is there anything else we should know?

After you hit submit, you will be redirected to our STRIPE Supporting Documents Upload Form. Please submit your supporting documents within 14 days of your online application. A member of the STRIPE financial team will follow up with you at that time. Please email all questions or concerns to stripe@theewefoundation.org.

If you have already submitted an application but need to submit your supporting documents, click here: SUPPORTING DOCUMENTS UPLOAD.

Your privacy is a our priority. The E.WE Foundation will never share your information without your consent. Please email admin@theewefoundation.org with questions about this form. Review our privacy policy here.

STRIPE Financial Assistance Request for Trisomy 18 Infants, Children, and their Families

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