Social Worker Form

  • André Sobel River of Life Foundation
    Everyday Needs Assistance Program


    For Single Parent Families of Children with Life Threatening Illnesses

    We are pleased to assist your family by paying for urgent everyday needs during your child’s treatment and when all other resources are exhausted.
    Kindly have your child’s social worker fill out this form and click "Submit" to send the application electronically


    Rev 07/2016

  • Assistance Currently Received by the Family
    Please put a check mark next to resources for which you have applied.

     


  • Accepted file types: pdf, jpg, gif, png.

  • If available, please provide copies of bills for which assistance is requested. ASRL will use this information to pay vendors directly. Use additional sheet if necessary.
    TO AVOID DELAYS… PLEASE PROVIDE ACCOUNT NUMBERS WHEN APPLICABLE,
    VENDORS WILL RETURN CHECKS WHEN UNABLE TO LOCATE THE ACCOUNT.

     


  • Specific request #1:

  • REQUIRED TO PROPERLY CREDIT ACCT

  • Specific request #2:

  • REQUIRED TO PROPERLY CREDIT ACCT

  • Specific request #3:

  • REQUIRED TO PROPERLY CREDIT ACCT

  • We ask permission to use your information in an effort to provide service and financial assistance for your family. This information may, with discretion, be shared on your behalf with service providers, utilities, landlords, etc. to aid and preserve your family’s financial welfare. We may also use information in order to promote the charitable goals of the Andre Sobel River of Life foundation and its partner hospitals. If you do not want your information disclosed, please advise us, in writing, at the Andre Sobel River of Life Foundation, info@andreriveroflife.org. If you do not want your information disclosed, this will not affect ASRL’s willingness to assist your family.

     

  • By checking the box I agree that information I have entered above is completed and will be the electronic representation of my signature.

  • *If parent/guardian has Limited English Proficiency, please add interpreter’s signature attesting to interpretation in parent’s home language.