Once we receive your application for assistance, an interview will be scheduled with your family to further discuss your needs.  Once the interview is completed, the Board will review all details of your application and decide how we can best be of assistance. Thank you for taking the time to submit your information.  Please understand that is our desire to help every family that requests assistance, but unfortunately, the reality is, we just don’t have the funds to help every family.  

APPLICANT INFO
Applicant Name *
Applicant Name
Person completing this form
Applicant Address *
Applicant Address
Applicant Phone *
Applicant Phone
BENEFICIARY CONTACT INFO
Beneficiary Name *
Beneficiary Name
Beneficiary Address
Beneficiary Address
Phone 1
Phone 1
Steps Together reserves the right to request evidence of residency.
Steps Together reserves the right to request proof.
Please explain / list ages of any dependents.
Please explain.
Please explain.
DETAILS
Please provide a detailed explanation of the reason the family needs the support of Steps Together. Please include patient name, diagnosis, date of birth and date of diagnosis. Any applicant reapplying for support needs to only provide an update.
Lost income, unreimbursed medical expenses, extensive hospital stays, etc.
Please provide additional info here that would be relevant to your application. This can include any non-medical expenses such as transportation to and from treatment, home aide). Also include any steps the family has taken which may skew financial information (example - a parent taking on two jobs to help cover expenses).
Please list your monthly expenses including mortgage / rent, electric, water, car/insurance, gas, phone, child care, prescriptions, other.
Financial Documentation
Applications must include the submission of the first two pages of the family's most recent federal income tax return. Please black out all Social Security #'s before sending.
How can Steps Together help?