Please submit this Program Request to Jack’s Helping Hand by mail, fax, email, or in-person. Once received, our staff will contact the program management. We will contact you as soon as possible for next steps!
If no, please fill out New Child Application on our website or in our office.
In order to advance programs in conjunction in the medical treatment of
1. The undersigned are parents or legal guardians of the child
2. The undersigned acknowledge(s) and agree(s) to maintain records that will be made available to Jack’s Helping Hand upon reasonable request, detailing the expenditures made with assistance provided by the organization.
I have read the guidelines for program requests and eligibility checklists stated in New Child Application and I declare that the information furnished on this request form is true and correct to the best of my knowledge.