Application

I. Application Requirements

1) The child seeking a sponsorship is an adopted male or female through the age of 18.
2) The adopted parent or guardian must fill out the application form completely and sign.
3) In a 1500 words or less cover letter or email, clearly explain how this sponsorship will assist you in achieving your child’s treatment goals. Explain exactly how you will use the requested funds. State the amount of funds required to achieve your goals. Cover letters must be typed or printed neatly and submitted with completed application.
4) A copy of a therapist or doctor’s recommendation and diagnosis.
5) A copy of the sponsorship child’s primary & secondary medical insurance card front and back.

Please Note: The approval of the sponsorship application is at the sole discretion of the Adoptive Families Coalition Committee. All documents are kept confidential.

II. Applicant Information



















Employment


Does this company have a matching donation program? YesNo



Does this company have a matching donation program? YesNo

Insurance
Health Insurance? YesNo

What mental health coverage is offered by your insurance company to cover the
particular services needed for your child?

Do you need help researching benefits and/or submitting claims? YesNo

III. Sponsorship Child Information









MaleFemale

Adoption



Type of AdoptionPrivateAgencyFoster Care

Behaviors
Current Diagnosis:


Behaviors Exhibited:

Financial Information

What financial resources have been utilized until now for the treatment of your child?

Have you applied for other funding resources and if so, through what organization and what amount of funds did you receive?

Treatment Issues
Does your child have legal issues? YesNo
Does your child have an IEP? YesNo
Has he/she had a comprehensive psych evaluation? YesNo

Funds raised for therapeutic treatment of sponsorship recipients through Adoptive Families Coalition are tax deductible to the extent allowed by law. Only the amount of recommended sponsorship funds donated will be forwarded to the treatment provider. No donations will be distributed directly to the recipient or their family. Adoptive Families Coalition does not make up any shortfall between what is donated and what the treatment provider invoices. Parents of the recipient cannot contribute to their own child’s sponsorship account. 100% of all recommended donations will go directly for treatment, as generous donations have covered the cost of
operations. All donations to Adoptive Families Coalition recommended for a specific child are under the sole discretion of the Adoptive Families Coalition Board. Donated funds exceeding the total amount of treatment and/or unused for the recipient are not refunded to the recipient family, but remain in the sponsorship program.

Select Treatment of Interest
Residential Treatment Center up to 18 monthsPsychologist/Psychiatrist Services up to 3 yearsAttachment, EMDR, and/or Neurofeedback Therapy up to 3 yearsOther

No medication costs will be considered for Adoptive Families Coalition sponsorship coverage.

I hereby certify that the information I have submitted is correct. I authorize the release of this information to members of the Adoptive Families Coalition Sponsorship Committee and will provide additional information or verification upon request.


You can upload the necessary documents as pdf, jpg, png, gif, and word document files. Please make sure files are under 10mb.