Child Information

Child’s Name:

Child’s Age:

Child’s Date of Birth:

Child’s Gender
FemaleMale

Is the child actively receiving treatment?
YesNo
If no, when did your child last receive treatment?

Child’s Diagnosis:

Child’s Date of Diagnosis:

Is your child’s treatment being facilitated at a hospital?
YesNo
If yes, which hospital?

Please attach a physician’s form. (A letter stating the child’s diagnosis signed by the child’s medical provider.)

Household Size

How many people currently live in your household?
12345+

Does the child have siblings?
YesNo
Please list the name and age of each family member:

Parent’s Information

Parent’s name

Parent’s email

Parent’s phone

Parents complete mailing address

Parent’s social media account URLs

What has been your biggest challenge and need in fighting against childhood cancer?

How did you hear about Leia’s Kids?

Social Worker Name, Email, and Phone Number:

Confidentiality Statement

Your responses to the following questions will not disqualify you from receiving assistance. This information is collected solely for data collection and program expansion purposes. All responses will remain confidential and will not impact your eligibility for assistance.

What is your race/ethnicity? (Please select all that apply)
American Indian or Alaska NativeAsianBlack or African AmericanHispanic or LatinoNative Hawaiian or Other Pacific IslanderWhiteMiddle Eastern or North AfricanPrefer not to sayOther
Other: (if needed):

Household & Financial Information

Military Status

N/AActiveReserveVeteran

Health Insurance

Does your child have health insurance?
YesNo
If yes, which provider?
TricarePrivate InsuranceEmployer SponsorMedicaidCHIPMedicareMarket PlaceAffordable Care ActOther (check the box)
If Other, which provider?

Household Income

What is your estimated annual household income??
Under $25,000$25,000 – $49,999$50,000 – $74,999$75,000 – $99,999$100,000 – $149,999$150,000+
Estimated Household Income After Diagnosis:

Additional Financial Burdens

Are there other medical needs in your household? (For example, another child undergoing treatment, a family member with a chronic illness, disabilities, neurological conditions such as epilepsy, or any other medically complex needs.)

Are there other financial burdens you would like to share? (e.g., a child in college, single-family income, other major expenses)

Financial Impact of Cancer

Has a cancer diagnosis impacted your household financially?
If so, please describe how (e.g., loss of income, increased medical expenses, caregiving responsibilities, etc.):

Has a parent/caregiver stopped working or reduced hours due to your child’s illness?
YesNoReduced Hours

Financial Assistance

Are you currently receiving any financial assistance? (Check all that apply)
MedicaidSocial Security Disability (SSI/SSDI)Food Stamps/SNAPHousing AssistanceOther Non Profit AssistanceOther
If Other, specify here:

Financial Challenges

Have you faced any of the following financial struggles due to your child’s illness? (Check all that apply)
Difficulty paying rent/mortgageUtility shutoff noticesCar payments or transportation issuesMedical debtBankruptcyEviction riskOther
If Other, specify here:

Grant Use

How do you plan to use this grant? (Check all that apply & explain below)
Medical expenses not covered by insuranceTravel/lodging for treatmentsMortgage/rent assistanceUtilities (electric, water, etc.)Groceries/food supportChildcare for siblingsEducational support (tutors, online schooling, etc.)Other
Additional Explanation (if needed):

Please attach your most recent tax return.

Please upload a picture of your warrior here:

By checking this box, I give my permission for Leia's Kids Foundation and/or its representatives to use artwork, photographs and/or letters/the story that I provide of my child, my family, and/or myself in publications, slides, videotapes, motion pictures and/or on the Internet. In addition, I hereby give my permission for Leia's Kids and/or its representatives to photograph, audio tape record, and/or videotape my child or myself and to use our names, these images or voice recordings in publications, slides, videotapes, motion pictures and/or on the internet. I understand these visual images or voice recordings may be used to inform families, volunteers, donors, the media and general public about Leia's Kids programs, services or events. I gladly give this authorization to support the efforts of Leia's Kids. I understand this authorization shall continue until terminated in writing. Providing consent is not a requirement in order to participate in Leia's Kids programs.

By checking the box, I give permission to be contacted about Leia's Kids by SMS text at my residential or cellular number or provided email address, dialed manually or by autodialer (consent to be contacted is not a condition to participate) and to be contacted via email. I consent to be contacted even if my phone number or email address appears on a Leia's Kids Do Not Call / Do Not Email List, a State or National Do Not Call Registry, or any other Do Not Contact List.