application

The Chestnut Foundation is a non-profit organization dedicated to providing assistance to families who have multiple disabled children. We determine
eligibility of these families by application process. Upon verification of this information, we contact the families to conduct interviews of each family member,
their friends and their neighbors. Once the interview is conducted, we proceed with aid to these families, based on their immediate needs. To achieve our
goals, we host fund raising events throughout the year to raise funds to help support these families in their time of need. All proceeds go to aid these
families in the support, welfare, and care of their children. This aid is in the form of financial assistance, medical supplies, adaptive equipment, and personal
assistance is applying for government aid.

All information obtained is strictly confidential . The information which you provide will be used exclusively by the Foundation to determine your eligibility for
assistance. The Foundation will not disseminate or release the provided information to outside sources without first obtaining prior express written consent.
The following information is being submitted by the applicant in consideration of possible assistance.

THE CHESTNUT FOUNDATION


	Date:________________________________ Applicant Name:_______________________________________ Age:__________ Date of birth:__________________ Gender: ________ Mailing Address:__________________________________ City:________________________ State: _____ Zip Code: __________ Telephone Number(primary): ___________________ Telephone Number (secondary): ____________ Email:___________________________________ Referred by:____________________________ Name of Applicant's Legal Guardian: _______________________________ Relationship to Applicant: ______________________________________ The following information is used to determine applicant's need for help. It will be shown only to the Board of Dorectors of the Chestnut Foundation and will not be divulged to any other party. Additional information may be requested at the discretion of the Board of Directors of the Chestnut Foundation. How many people reside in your household? _____________ List currect sources of income for applicant, yourself, and all other members of your household below:

	____________________________________________________________________________________________________________ APPLICANT YOURSELF (if not applicant) OTHER HOUSEHOLD MEMBERS Wages _________________ __________________________________ _________________________ Social Security ________________ __________________________________ ________________________ Disability Income ________________ __________________________________ ________________________ Medicaid ________________ _________________________________ ________________________ Other Income ________________ __________________________________ _________________________ _ Total Household Income ________________ __________________________________ _________________________


Do you or your family own or rent the home in which you are living? __________________ Type of assistance requested (please check all that apply): _______ Financial assistance _______ Adaptive equipment _______ Assistance with applications for government aid _______ Other medically-related need (please explain): ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ The Board has no way of knowing you except through this application. Therefore, we would like you to tell us your "story" so that we may better understand your need for assistance. Please attach a one page typed or printed story to be submitted with your application. Please mention any other facts you would like us to consider when determining your eligibility for assistance. In addition to this application, we may conduct a phone interview and/or schedule a home visit. Do we have your permission to contact you? Yes ________ No ________ GENERAL PUBLICITY RELEASE I/we wish to participate in benefits provided by The Chestnut Foundation. I/we understand that our participation in such a program is wholly voluntary and that these benefits are provided by The Chestnut Foundation in furtherance of its humanitarian endeavor to provide support to families struggling with multiple disabled children. I/we hereby release, discharge, indemnify, and agree to hold harmless The Chestnut Foundation, its Officers, Directors, Agents, Sponsors, and Volunteers from all claims, demands, causes of action, present or future, whether known, anticipated or unanticipated, resulting from, arising out of, or incidental to our participating in the program or benefits provided by The Chestnut Foundation. I/we understand and agree that fulfillment of assistance may result in publicity, whether or not The Chestnut Foundation acively takes steps to publicize its services. I/we understand that there is a limit to the number of services that I/we will receive, depending on the type and cost of services being provided. I/we understand and agree that no promises or assurance whatsoever have been made to me by any representative(s) of The Chestnut Foundation regarding the assistance I/we am/are requesting. The Chestnut Foundation may hold events and fundraisers throughout the year to fund the primary objective of the foundation: to help families of multiple disabled children meet unfunded medically-related needs. People continue to support us because they want to see their money find its way to the people who need it most. We need you to help to put a face and name to that reality. To this end, we ask for your permission to use your photo, your story, and a brief description of how the money and/or services that you received from The Chestnut Foundation has helped you. This will assist us in communicating to our sponsors and donors and help in attracting more contributors so that we can do more. Please indicate your permission by checking the appropriate areas below: _______ Use of photo _______ Your background information/"story" _______ First name only _______ First and last name Permission to use the checked information above is given to The Chestnut Foundation for use in public relations and marketing materials which will include, but are not limited to, its annual report, newsletters, website, mailings, and general information brochures. Name: ______________________________________________ Signature:____________________________________________________ Date: _________________ When you have completed this form, please print it, enclose your "story" with it, and mail it to us. Our address is: The Chestnut Foundation Attn: Applications 102 Elmwood Avenue Narberth, PA 19072 If you need assistance completing this application, please contact Donna at donna@thechestnutfoundation.org. We will be glad to provide assistance. If you prefer to have us send an application to you in the mail, please go to our "Contact Us" page and leave your name and address there. Thank you.