Apply for Assistance - Evergreen Hope Mission

🙏 All information is kept strictly confidential and used only for assistance evaluation

Parent/Guardian Information

First Name *

Last Name *

Email Address *

Phone Number *

Relationship to Child *

WhatsApp Number (if different)

Home Address *

Child Information

Child's First Name *

Child's Last Name *

Date of Birth *

Gender *

Medical Information

Hospital/Clinic Name *

Hospital Location *

Child's Medical Condition *

Treatment Required *

Estimated Total Cost *

Urgency Level *

Doctor/Physician Name

Medical Documents

📎 Click to upload medical reports, prescriptions, or hospital bills (optional but helpful)

Financial Situation

Primary Income Source *

Monthly Household Income *

Number of Dependents *

Why do you need assistance? *

Have you received help from other organizations?

Additional Information

How did you hear about Evergreen Hope Mission? *

Your Faith Community (Optional)

Prayer Requests

Additional Information

I confirm that all information provided is true and accurate to the best of my knowledge. I understand that Evergreen Hope Mission will verify this information and that providing false information may result in denial of assistance. *

I consent to being contacted by Evergreen Hope Mission via phone, email, or WhatsApp regarding this application. *

I authorize Evergreen Hope Mission to contact the hospital and verify the medical information provided. *

Apply for Medical Assistance

Parent/Guardian Information

Child Information

Medical Information

Financial Situation

Additional Information