Kartini Foundation Online Application Form
The Foundation is currently accepting applications for grants to help provide funding for appropriate medical treatment of eating disorders in children and young adults, to age 18. Applications and all supporting documents must be submitted electronically. Attachments may be submitted to help@kartinifoundation.org. We make every effort to process applications promptly. Thank you.
Patient's Name and Date of Birth *
Please use their full legal name and date of birth, e.g. 4/12/94
Parent(s) or Legal Guardian's Name *
Please list all parents (first and last name) or legal guardians who have sole or joint custody of the patient.
Home Address *
Please include complete mailing address, city, state, and zip code.
Email address *
Please submit a current email address. This is where you will receive all communications regarding your application.
Contact phone number *
Please also leave a telephone number in case we are unable to reach you via email.
What is your child's current diagnosis? *
If you are unsure please ask your referring physician or provider.
Required
List any past treatment along with the names of the providers and dates. *
Please list other sources of income. *
Briefly describe your family’s finances. Include a description of all sources of income, health insurance, your family’s other health-related expenses, and any other information the Foundation may find useful in determining your financial needs. *
What other funding options has your family looked into? *
Please email electronic copies of the last two years of your federal and state income tax returns, documentation regarding other sources of income, and a copy of your Kartini Clinic treatment estimate to help@kartinifoundation.org. Applications without this documentation will not be considered. Thank you.
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