555 Hemphill Street, Suite 200 Fort Worth, Texas (817) Hours: Monday Friday, 8:30AM 3:30PM Fax: (817)
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1 Gill Children s Services 555 Hemphill Street, Suite 200 Fort Worth, Texas (817) Hours: Monday Friday, 8:30AM 3:30PM Fax: (817) Gill s Mission Gill Children s Services is a funding source of last resort that provides a safety net for Tarrant County Children whose medical, dental, physical, social, psychological, and educational needs have not been met by other community resources. Who can apply? Gill Children s Services helps children when all other resources have been exhausted. Before applying, please ask yourself: 1. Is my child 0-18 years old? 2. Does my child live in Tarrant County? 3. Have I called United Way s 211 Resource Line to see if other nonprofits can help me? If you answered YES to all three questions, you may apply for assistance from Gill Children's Services. To get a copy of our application, you can: Pick up an application at our office Ask us to mail an application to your home Print off the application from Application Instructions The following information can be faxed to (817) or mailed to 555 Hemphill Street, Suite 200, Fort Worth, TX Gill must have ALL of the following documents to process your request: Complete Application for Financial Assistance Application (pages 1-4) Acknowledgement and Authorization (page 5) Income Verification (paycheck stub, letter from employer, etc.) Other: Depending on the service or equipment you are requesting, Gill may need additional information. Please call our case managers with questions. For all dental requests, contact: Alice Espinoza, Dental Case Manager (817) ext. 102 aespinoza@gillchildrens.org For all non-dental requests, contact: Alex Estrada, Case Manager (817) ext. 101 aestrada@gillchildrens.org
2 Section 1: Service Information Gill Children s Services 555 Hemphill Street, Suite 200 Fort Worth, Texas (817) Hours: Monday Friday, 8:30AM 3:30PM Fax: (817) Application for Financial Assistance 1A. What do you need financial assistance with? List in order of importance B. What is the total cost of what you are requesting? $. How much are you able to contribute to the cost of the service? $. How much are you requesting from Gill Children s Services? $. 1C. Do you know who will be providing the services requested? No Yes: Address Phone Fax 1D. Please explain why you need Gill s assistance at this time. 1E. Have you received assistance from Gill Children s Services before? No Yes: Section 2: Referral Information 2A. How did you hear about Gill Children s Services? 2B. Do you have a relationship with anyone on Gill s staff? No Yes: 2C. Have you called or visited Yes No 2D. Have you applied anywhere else for help? Agency Name Reason for denial Agency Name Reason for denial 2E. Provide a contact as a reference (Social Worker, school counselor, case manager, etc.) Name Organization (if applicable) Phone 2F. In case we cannot reach you, please list nearest friend or relative. Name Relationship Phone 1
3 Section 3: Child Information 3A. Fill out the following information for ALL children in your household. Please indicate which children need the services, goods, or equipment you described in Section 1. 2
4 Section 4: Parent/Guardian Information 4A. Fill out the following information about the child s parent or guardian. Please indicate which parent(s) should be the primary contact for your application. This parent/guardian is the primary contact for this request Relationship to child: Mother Father Legal Guardian Other: Name: Address: Number Street Apt. City State Zip Contact Information: Home Phone Cell Phone Marital Status: Language: English Spanish Other: Employment: Employer Address $ Amount per month Unemployed This parent/guardian is the primary contact for this request Relationship to child: Mother Father Legal Guardian Other: Name: Address: Number Street Apt. City State Zip Contact Information: Home Phone Cell Phone Marital Status: Language: English Spanish Other: Employment: Employer Address $ Amount per month Unemployed 3
5 Section 5: Financial Information 5A. How many people live in your household? 5B. Please list the family s monthly financial obligations. Rent/Mortgage Payment $. Electricity $. Gas $. Water $. Food/Groceries (Do not include food stamps) $. Cell Phone $. Car Payment $. Gas/Transportation $. Car Insurance $. Child Care $. Hygiene/Personal Expenses $. Major Credit Cards (Total Balance: $ ) $. Loans (Total Balance: $ ) $. Medical Bills $. Other (Please specify): $. 5C. Does the child/parent receive any of the following support? Child Support No Yes Monthly Amount: $. TANF No Yes Monthly Amount: $. SNAP/Food Stamps No Yes Monthly Amount: $. Social Security (Retirement or SSI/SSD) No Yes Monthly Amount: $. Housing No Yes WIC No Yes Other: No Yes Monthly Amount: $. Office Use Only Date received: Missing documents: Approved Denied: Initial: Household ID #: Client IDs#: Known conflicts of interest with the applicant? No Yes: 4
6 Section 6: Acknowledgement and Authorization 6A. Acknowledgement of Funding Services Gill Children s Services, Inc. ( Gill ), a 501(c)(3) non-profit charity, is a funding source of last resort that provides a safety net for Tarrant County children whose medical, dental, physical, social, psychological and educational needs have not been met by other community resources. Gill provides funding only when the family s and community s resources have been exhausted. By signing below, you acknowledge and agree, on behalf of yourself, your spouse (if applicable), and the minor child for whose benefit funding is sought (all collectively, Recipient ), as follows: 1. Gill is providing funding for Recipient to obtain services from a third-party provider and will issue payment directly to such third-party provider. No funds will be directly paid to Recipient. 2. Gill is not responsible for the conduct of any third-party provider that provides services to Recipient. Recipient is solely responsible for choosing to use such third-party provider of services and for the course of treatment that Recipient selects. 3. IN CONSIDERATION FOR THE FUNDING GILL IS PROVIDING RECIPIENT, EACH RECIPIENT AND THEIR RESPECTIVE HEIRS AND PERSONAL REPRESENTATIVES, HEREBY RELEASES GILL AND ITS RESPECTIVE EMPLOYEES, OFFICERS, DIRECTORS AND AGENTS (COLLECTIVELY "RELEASEES") FROM ANY AND ALL CAUSES OF ACTION, CLAIMS, LIABILITIES OR DAMAGES WHICH MAY NOW OR HEREAFTER BE SUFFERED BY RECIPIENT THAT RELATE IN ANY WAY TO OR ARISE OUT OF THE SERVICES FOR WHICH GILL IS PROVIDING FUNDING (THE SERVICES ) AND AGREE (I) NOT TO BRING ANY CAUSE OF ACTION OR CLAIM OF ANY KIND WHATSOEVER AGAINST ANY RELEASEE ARISING OUT OF OR RELATED TO, DIRECTLY OR INDIRECTLY, THE SERVICES, INCLUDING WITHOUT LIMITATION, ANY INJURY OR DAMAGE TO ANY PERSON OR PROPERTY RESULTING FROM THE SERVICES OR ANY CLAIM THAT IS BASED ON THE SOLE, JOINT, OR COMPARATIVE NEGLIGENCE OF GILL; AND (II) THIS ACKNOWLEDGMENT OF FUNDING SERVICES SHALL BE A COMPLETE DEFENSE TO, AND A CONSENT TO THE DISMISSAL OF, ANY CAUSE OF ACTION OR CLAIM BROUGHT AGAINST GILL IN CONTRAVENTION HEREOF. 4. This Acknowledgement of Funding Services shall be governed by and construed in accordance with Texas law, and any dispute between Gill and Recipient must and may only be brought in a court of competent jurisdiction in Tarrant County, Texas. 5. Recipient has carefully read this Acknowledgement of Funding Services, understands its contents and has signed it freely and voluntarily with full knowledge of its contents, and the person signing on behalf of the minor child is the parent or legal guardian of such child and authorized to sign on his or her behalf. Parent/Guardian Signature On behalf of minor Date 6B. I grant permission to Gill Children s Services, Inc. to use a summary of my child s case for any and all purposes related to public education and/or promotion of Gill Children s Services. I further grant permission for Gill Children s Services, Inc. to use, publish, and or display any artwork created by my child for Gill Children s Services. I release any and all rights to images created and prepared and release Gill Children s Services from any and all claims or liabilities resulting from their use. I further understand that once the case information/artwork is disclosed, it may be redisclosed by the recipient or by Gill Children s Services and the information may not be protected by federal privacy laws or regulations. I understand I may revoke this authorization at any time by notifying Gill Children s Services in writing at 555 Hemphill Street, Suite 200, Fort Worth, TX of my intent to revoke this authorization. I understand that such revocation will not have any effect on any actions taken by Gill Children s Services, Inc. before the receipt of the revocation. Parent/Guardian Signature On behalf of minor Date 5
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