Warning! You do not currently have javascript enabled.
You need to have javascript enabled in order to use this form.
Click here for help.
Jess's Sunshine Fund Application
Jess's Sunshine Fund provides financial assistance to families who are residents of the Boyertown Area School District with dependent adult or minor children who have special needs arising from a long-term catastrophic illness or injury.

Please complete the following information and click submit. Applications are reviewed in March and October each year.

The deadline for the current application cycle is August 31, 2008. Please complete and submit the form below to apply for a grant from Jess's Sunshine Fund.

Dependent's Name: 
Prefix
First
MI
Last
Suffix
 
 
 
 
 

Date of Birth (mm/dd/yyyy): 
 

Street Address:
 

Address 2 (optional):
 

City:  

State:   Zip Code:   County

Phone Number (xxx xxx-xxxx):  

Parent Name: 
    

Parent address and phone number (if different from dependent):

Street Address:
 

Address 2 (optional):
 

City:  

State:   Zip Code:  

Phone Number (xxx xxx-xxxx):  

 

Email address:  

Names and ages of siblings: 

 

Dependent's diagnosis and brief history of illness: 

 

Amount of assistance requested:  

Item(s) to be covered by financial assistance:  

Does the dependent have insurance coverage? 

Yes No 

If yes please list insurance and limitations of coverage:  

How did you hear about the Community Foundation?