Apply For Support

Apply for support

* Indicates required field

Child's Name *

First

Last

Name of Parent/Caregiver *

First

Last

Please list your name, and affiliation if you're filling this application out on the families behalf *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Email *

Phone Number *

Age *

DOB *

Gender *

Male Female

Insurance *

Yes No

Select One *

If your insurance carrier isn't listed, please specify what carrier you have *

Medicaid *

Marital Status *

How many people live with applicant *

Employment Status *

If not currently working, please describe reason (Appointments hinder my ability to hold a job, stay at home mom, etc.) *

Employer *

Employer Phone *

Household Income (Please include SSI, child support or any other income) *

Primary Care Physician *

Primary Care Phone Number *

Neurologist/Psychiatrist *

Neurologist Phone Number *

Hospital Affiliate *

If you selected "other" specify the Hospital your child is seen at *

Diagnosis (If your child is undiagnosed, please describe symptoms) *

Prognosis *

Have you received support from any other foundations or charities *

Yes No

If yes, then please include what charity or foundation, the year you received the support and what the support consisted of *

Tell us a little bit about how we can help bless your family today. Please be as specific as possible with what your need is. *

I agree to allow Bethany's Butterflies Foundation Inc. to use name/photos of the applicant for testimonials *

I agree to allow Bethany's Butterflies Foundation Inc. to contact my employer for verification of employment *

Submit