Application for Financial Assistance

We would like to thank the generous donors who have established a scholarship fund to help families cover the costs of tube weaning. If you are interested in becoming a donor, please contact us at info@gieaters.com.

If you would like to be considered for financial assistance, please fill out the form below. Completing this form does not guarantee that you will qualify for a full or partial financial assistance. Priority is given to families with the greatest financial need. If donations run out, remaining families will be put on a waitlist for future opportunities.  Any financial assistance is conditional on an approved Intake Form.

Parent Information
Parent/Guardian Name *
Parent/Guardian Name
Address *
Address
Phone *
Phone
Child Information
Child's Name *
Child's Name
Child's Gender *
Child's Date of Birth *
Child's Date of Birth
Employment
Employment Status *
Household
List name, dates of birth, relationship to patient, are they also applying for financial assistance -- like, if we are weaning twins, etc.
$
Rent/mortgage, insurance premiums, other debt expenses (child support, loans, credit cards, etc.), medical expenses, utilities, other.
$
$
Additional Assets *
Check all that apply
$
Terms and Conditions
*
*
*
*
*