The Foundation provides financial
assistance to families who have a child
receiving pediatric hospice care services,
and are unable to pay for critical
unfunded expenses. This can include but is not limited to paying utility bills, health insurance premiums, mortgage/rent payments, or other urgent, one-time emergency expense.
*SPECIAL NOTE: the Foundation CANNOT pay an individual (landlord, person making home repairs, etc.) unless a W9 form is submitted by that individual. This includes individuals who own their own company, e.g. “Wilson’s Repair Service.” W9 Forms and instructions can be found HERE. Please contact us directly if you have ANY questions about this requirement.
Pediatric Financial Assistance Requests
Please download and read the Guidelines before proceeding. Applications will be filled out by the patient's parent or legal guardian, and returned to the hospice/palliative care worker. It is the responsibility of the caseworker to submit the application and supporting documents on behalf of the patient/family.
***The caseworker must also provide written proof (signed and on company letterhead) that the patient is currently receiving hospice or palliative care services, or if deceased, proof of the dates that the patient was on service.
Please download and print the application for your patient's parent to complete. The caseworker may guide the process, but the application MUST be completed by the patient's parent or legal guardian. Please note that the application will not be processed without supporting documentation as detailed in the document.
Individuals and Families must be at or below the poverty line to be eligible for Financial Assistance. To determine if an individual or family qualifies please review the poverty guidelines.
If the parent of the patient is not the person filling out the application, this form must be utilized to verify permission for an authorized person to fill out the application on the patient's behalf. If the child has a different last name than the parent or authorized person, a copy of the child's birth certificate will be required.
When the application is complete and supporting documents have been obtained, please submit in .pdf form to email@example.com. ***Photos will not be accepted, please provide copies of originals. Contact us at if you have any questions.
If you, your family member, or your patient has received assistance from our Pediatric Care Program, please take a minute to provide feedback.
Other Pediatric Requests
If you are a child life specialist for a pediatric hospice patient and need to apply for a photography session on behalf of your patient.
If you are a nurse, social worker, or child life specialist for a pediatric hospice patient and need to request a small gift on behalf of your patient.
If you are a child life specialist for a pediatric hospice patient and need to complete a charm request on behalf of your patient.
"The Hospice and Palliative Care Foundation ensured that a pediatric patient and his family would continue to make memories despite his terminal diagnosis. The family had a minivan that had not worked in many years unfortunately this was the only automobile that would comfortably fit the patient and his entire family. With the assistance of the foundation, the family was able to purchase a new motor for the minivan. Now the family will be able to travel together and make new memories during this precious time. "
-Social Worker of Pediatric Patient
"It was a great stress relief. It was a blessing. Without the Foundation people like us would be in a world of trouble. We so greatly appreciate the assistance."
-Parents of Pediatric Patient
"No family prepares for the financial burden of the loss of child. In one particular case, our patient's parents were working hard to simply make ends meet. When their child passed away they worried they would not be able to pay for their child's burial. The foundation offered peace of mind and comfort in knowing they would have the finances needed to honor their child the way they wanted."
-Social Worker of Pediatric Patient