Online Application

Fill Out Our Application Online



Required Documents

In order to complete the application online you will need to provide/upload the following documents:

Drivers License/Photo ID
Letter from a physician(s) confirming diagnosis
Copies of Invoices for payment (if applicable)
Copy of 1st page of bank statement (if applicable)



Financials

Before you begin please have a rough estimate of your current assets and monthly expenditures as it will be required in the application.

Criteria Of An Applicant

Applicant must be 18 years of age or younger experiencing a medical or living emergency. Applicant must reside in one of the following locations:

Staten Island, NY • Bergen County, NJ • Essex County, NJ • Hudson County, NJ • Middlesex County, NJ • Monmouth County, NJ • Ocean County, NJ • Union County, NJ

I Agree(Required)

That this grant application is on behalf of a child who is 18 Years old or Younger

Please Select Where The Applicant Resides(Required)

Please note that applicants MUST live in one of the areas listed in order to be considered for a grant.

Grant Request For:(Required)

Child's Information

Name(Required)

First Last

Date of Birth(Required)

Gender(Required)

Ethnic Origin(Required)

Parent/Legal Guardian "1" Information

Name(Required)

First Last

Relationship To Child:(Required)

Your Marital Status(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Home Phone(Required)

Cell Phone(Required)

Employer(Required)

Please put N/A if not applicable.

Employer Address:

Street Address Address Line 2 City State ZIP Code

Work Phone

Email(Required)

Enter Email Confirm Email

Parent/Legal Guardian "2" Information

Name

First Last

Relationship To Child:

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Home Phone

Cell Phone

Employer

Employer Address:

Street Address Address Line 2 City State ZIP Code

Work Phone

Enter Email Confirm Email

Are There Any Other Children in the Family?(Required)

Siblings Name

First Last

Birthday

Siblings Name(Required)

First Last

Birthday(Required)

Siblings Name(Required)

First Last

Birthday(Required)

Siblings Name(Required)

First Last

Birthday(Required)

Medical Information

We reserve the right to request medical records and/or letters from physicians

Do You Have Health Insurance?(Required)

Name Of Insurance Carrier(Required)

Name Of Policy Holder(Required)

First Last

State(Required)

Name Of Child's Physician

Physician's Address

Street Address Address Line 2 City State ZIP Code

Physician's Phone

Name of Child' Pharmacist

First Last

Pharmacy Address

Street Address Address Line 2 City State ZIP Code

Pharmacy Phone

HIPAA Consent(Required)

By Checking This Box I Provide Authorization for release of health information pursuant to HIPAA

I, or my authorized representative, request that health information regarding my care and treatment be released as set forth on this form: In accordance with New York State Law and the Privacy Rule of the Health Insurance Portability and Accountability Act of I996 (HIPAA), I understand that: I. This authorization may include disclosure of information relating to ALCOHOL and DRUG ABUSE, MENTAL HEALTH TREATMENT, except psychotherapy notes, and CONFIDENTIAL HIV* RELATED INFORMATION. In the event the health information described below includes any of these types of information, I specifically authorize release of such information to Board of Directors/Staff- Emergency Children's Help Organization, Inc., 3041 Veterans Road West, SI NY 10309. 2. I f I am authorizing the release of HIV-related, alcohol or drug treatment, or mental health treatment information, the recipient is prohibited from redisclosing such information without my authorization unless permitted to do so under federal or state law. I understand that I have the right to request a list of people who may receive or use my HIV-related information without authorization. If I experience discrimination because of the release or disclosure of HIV-related information, I may contact the New York State Division of Human Rights at (212) 480-2493 or the New York City Commission o f Human Rights at (212) 306-7450. These agencies are responsible for protecting my rights. 3. I have the right to revoke this authorization at any time by writing to the health care provider listed below. I understand that I may revoke this authorization except to the extent that action has already been taken based on this authorization. 4. I understand that signing this authorization is voluntary. My treatment, payment, enrollment in a health plan, or eligibility for benefits will not be conditioned upon my authorization of this disclosure. 5. Information disclosed under this authorization might be redisclosed by the recipient (except as noted above in Item 2), and this redisclosure may no longer be protected by federal or state law. 6. THIS AUTHORIZATION DOES NOT AUTHORIZE YOU TO DISCUSS MY HEALTH INFORMATION OR MEDICAL CARE WITH ANYONE OTHER THAN Board of Directors/Staff- Emergency Children's Help Organization, Inc., 3041 Veterans Road West, SI NY 10309

Grant Explanation

Please give a detailed explanation for the basis of this grant request such as: How does the child meet ECHO's grant criteria, range of funding being requested, basis for financial need.

Provide Your Explanation Below:(Required)

Financial Information

THE INFORMATION PROVIDED WILL BE USED SOLELY FOR THE PURPOSE OF QUALIFYING THE APPLICANT FOR A GRANT FROM ECHO AND WILL BE KEPT STRICTLY PERSONAL AND CONFIDENTIAL.

Section A Residence

Do You Own A Home?(Required)

Value of Your Home:(Required)

What is Your Outstanding Mortgage Amount?(Required)

Total Section A:

Section B Assets

Bank Account Balances(Required)

Investment Balances(Required)

Other Balance

Total Section B

Section C Liabilities

Credit Cards(Required)

Personal Loans(Required)

Other

Total Section C:

Your Net Worth

This is a result of adding totals from Section A and B together and then subtracting the total from Section C

Net Worth

Combined Household Monthly Income

Please fill in rough estimates for each category. Use 0 if it does not apply.

Net Salary/Wages(Required)

Public Aid

Pension

Disability

Grants

SNAP/EBT

Other Assistance

Other Income

Total Monthly Income

Household Monthly Expenses

Enter the amount you pay each month, EXCLUDING medical expenses related to your emergency. Use 0 if it does not apply.

Mortgage/Rent(Required)

EZ Pass(Required)

Gas/Heating(Required)

Medical Insurance(Required)

Electric(Required)

Medical Bills(Required)

Water(Required)

Co-Pays(Required)

Telephone(Required)

Prescriptions(Required)

Cable/TV(Required)

Groceries(Required)

Cell Phone(Required)

Credit Cards(Required)

Car Payments(Required)

Personal Loans(Required)

Car Insurance(Required)

Parking(Required)

Gas (car)(Required)

Other

Total Expenses:

Monthly Expenses Related ONLY to Your Medical/Living Emergency

Please fill in rough estimates for each category. Use 0 if it does not apply.

Medical Bills(Required)

Medical Equipment(Required)

Co-Pays(Required)

Prescriptions(Required)

Lodging(Required)

Gas (car)(Required)

Parking(Required)

EZ Pass(Required)

Other

Total Monthly Medical Expenses:

How Did You Hear About ECHO?(Required)

If 'other' Please Tell Us How You Heard About Us(Required)

Who Recommended You To ECHO?

Have You Received Financial Assistance From Any Other Organization? If yes, please list the name of the organization, date of assistance and the amount received.(Required)

References

Please list at least 3 references, and inform them that they will be receiving a call from ECHO's staff to verify your application.

Name(Required)

First Last

Phone(Required)

Name(Required)

First Last

Phone(Required)

Name(Required)

First Last

Phone(Required)

Please Upload a Valid Driver's License/Photo ID(Required)

Max. file size: 128 MB.

Please Upload a Letter From Your Physician

Max. file size: 128 MB.

Please Upload the First Page of Your Bank Statement

Max. file size: 128 MB.

Please Upload Any Additional Pertinent Information

Drop files here or

Max. file size: 128 MB.

Please Read Each of the Below Statements. Checking Each Box Signifies That You Understand and Agree to the Statements Below.(Required)

Conflict of Interest Policy(Required)

I have read the Conflict of Interest Policy and attest that:

No Director, Officer, member of the Advisory Board, employee or agent of the Corporation or any member of their family, is a family member of mine or has a close personal or business relationship with me.

Yes, a Director, Officer, member of the Advisory Board, employee or agent of the Corporation or a member of their family, is a family member of mine or has a close personal or business relationship with me

Please Disclose The Individual's Name and the Personal/Business Relationship You Have With Them(Required)

Media Consent(Required)

By submitting this application to ECHO I understand and agree that my and my co-applicant's name, image and/or likeness may be provided and/or disclosed to third parties, such as newspapers and other media organizations, for their publication and broadcast. I expressly authorize ECHO to provide and/or disclose my and my co-applicant's name, image and/or likeness to third parties, including media organizations, for their use and dissemination to the general public and agree to indemnify and hold ECHO harmless from any claims and damages arising there from.

I Agree

I Do Not Agree

Signature(Required)

Your digital signature will act as legal binder acknowledging your understanding of the application process.

Digitally Signed By(Required)

First Last

Fill Out Our Application Online

Required Documents

Financials

Criteria Of An Applicant

Child's Information

Parent/Legal Guardian "1" Information

Parent/Legal Guardian "2" Information

Medical Information

Grant Explanation

Financial Information

Section A Residence

Section B Assets

Section C Liabilities

Your Net Worth

Combined Household Monthly Income

Household Monthly Expenses

Monthly Expenses Related ONLY to Your Medical/Living Emergency

References

Join Our Mailing List

All set!

Contact Us

1-866-755-ECHO (3246)

(718)-967-9085

denise@echoorganization.org

Follow Us