2021 Megan's Wings Monthly Assistance Application
A Monthly Assistance Request must be made by a medical social worker or health care provider. If you are a family requesting monthly help, please contact your child's medical social worker to apply on your behalf.
This application is for long term monthly assistance for up to 3 months for A) gas/grocery cards or B) partial rent assistance. To qualify, a family breadwinner must have lost the ability to work due to their child's medical needs for 6 wks or more and the family is experiencing EXTREME financial difficulty paying bills. A letter from medical staff is required to substantiate the medical need. Here are examples of substantiated medical needs: long-term transplant, family relocated for medical reasons from out of state and has no income in Ca, long term treatment complications prevent a parent from working, or an end of life situation and parents are at the bedside. Limitations and restrictions will be used to ensure assistance is not abused. The awarded amount of assistance per month will be based on need and our availability of funds.
1. Type of Monthly Assistance Requesting?
Gas and/or Grocery Card Assistance
Partial House Payment
2. Provide a brief explanation of patient situation and financial hardship.
3. Explain why the family needs extended assistance for 2-3 months:
4. Has one or both parents missed work due to child's illness?
No, neither parent has missed work due to child's illness.
Yes, One Parent has missed work.
Yes, Both Parents have missed work.
One parent was not working before diagnosis.
Both parents were not working before child's diagnosis.
5. Please indicate total monthly income loss due to missed work caring for sick child?
less than $500
More than $2001
6. How long has or will the parent/guardian be off work?
More than 6 months
If the breadwinner parent/guardian is expected to miss work for 6 or more weeks due to treatment needs, please explain.
Name of the Person completing this application:
Requestor phone number:
Requestor email address:
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