Request for Assistance

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!

Date of Birth:*
Completed New Child Application?:

If no, please fill out New Child Application on our website or in our office.

A. Program Request

Aquatic Programs:
Little Riders:
Other Treatments or Therapies:
If yes, please explain:

B. Request for Equipment

Equipment/Item Requested:
Explanation of Request:
Ordering Information:
Other source of assistance?:
If yes, please explain:
Other Notes/Comments:

C. Other Request

Explanation of Assistance:
Other source of assistance?:
If yes, please explain:
Other Notes/Comments:

D. Acknowledgement

In order to advance programs in conjunction in the medical treatment of

Child Name:

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.

Acknowledgment of Responsibility signed:*
Parent/Guardian Name:*
Parent/Guardian Signature:*
Acknowledge Signature:
Relationship to Child:*
Other Relationship: