APPLICANT INFO
If completing this form on behalf of a beneficiary, the family must be aware and have approved the submission of this application on their behalf.
Applicant Name *
Applicant Name
Person completing this form.
Applicant Address *
Applicant Address
Applicant Phone *
Applicant Phone
BENEFICIARY CONTACT INFO
Beneficiary Name *
Beneficiary Name
Beneficiary Address
Beneficiary Address
Phone 1
Phone 1
Steps Together reserves the right to request evidence of residency.
Steps Together reserves the right to request proof.
Please explain / list ages of any dependents.
DETAILS
Please provide a detailed explanation of the reason the family needs the support of Steps Together. Please include patient name, diagnosis, date of birth and date of diagnosis. Any applicant reapplying for support needs to only provide an update.
Lost income, unreimbursed medical expenses, extensive hospital stays, etc.
How can Steps Together help?
Confidentiality Statement *
By signing and submitting this application, you agree not to publicize the amount and type of any initial grant or subsequent grant to you by Steps-Together, including without limitation, sharing this information with other past, current or prospective Steps Together beneficiaries.