Application – Parker H. Bainter Org

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Welcome
About Us
News & Events

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The Parker H. Bainter Foundation, a registered 501c3 Non-Profit Organization, was established to help support families with children in the hospital. The Foundation does this by donating gifts to the children, offsetting expenses associated with having a child in the hospital (from parking, dining in the cafeteria, time off from work, or transportation to and from the hospital). It all adds up. In most situations, it is not an expected or predicted expense and one that can quickly consume a family’s savings account. The Foundation also raises overall awareness in areas that impacted Parker’s life such as donating blood and information regarding his medical condition.

Please complete the following application as thoroughly as possible.

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Parent Information (required)

Parent A

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Parent A First Name

Parent A Last Name

Permanent Address

Address Line 1 *

Address Line 2

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City *

State *

Postal Code *

Parent B

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Parent B First Name

Parent B Last Name

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Permanent Address

Same as Parent A

Same as Parent A

Address Line 1 *

Address Line 2

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City *

State *

Postal Code *

Contact Information (required)

Who should we contact with any questions?

Full Name of contact *

How should we contact you?

Email
Text
Phone

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Phone Number 1 *

Checkboxes

Mobile
Other

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Phone Number 2

Checkboxes

Mobile
Other

Email 1 *

Email 2

Could The Parker H. Bainter Foundation contact you on Facebook?

Please LIKE The Parker H. Bainter Foundation so we can find you and contact you more easily.

If we need to mail something to you, which address should we use?

Parent A Address
Parent B Address
Other

Address Line 1 *

Address Line 2 *

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City *

State *

Postal Code *

Is either parent unemployed at this time?

Yes
No
Both

Is either parent currently working?

Yes
No
Both

Child’s Information (required)

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Child’s First Name *

Child’s Last Name *

Child’s Date of Birth

Child’s Place of Birth *

Is the child hospitalized at this time?

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Name of Hospital

Unit

How long has child been hospitalized

What is the child’s current diagnosis?

Is the child covered under health insurance at this time?

Does the child have any siblings?

Sibling’s First Name *

Sibling’s Last Name *

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Social Worker First Name

Social Worker Last Name

Social Worker Email

Have you ever held an event or GoFundMe to raise funds for your family?

Please indicate how The Parker H. Bainter Foundation could best help you and your family at this time

Child Expenses*
Personal items
Paying a utility bill*
Hospital Cafeteria Meals
Travel Expenses*
Prayer
Other

Please list the specific amounts needed and any additional information

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Child Expenses

Additional Information

Utility Bill

Additional Information

Who should the donation check be made out to?

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Donation check recipient first name

Donation check recipient last name

*NOTE: If you are requesting assistance with a utility bill, travel expenses, childcare, or personal items, The Parker H. Bainter Foundation will need to know where you shop for personal items, where you purchase gas and if you primarily need hospital cafeteria gift/meal cards. For us to pay a bill, we need to know the account number, the name of the person on the account, the amount of the outstanding bill and a phone number for the company needing payment (if at all possible).

Please explain how your current situation has affected your family, and what your greatest needs are at this time. Thank you.

Write your message here...

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Parent A Signature 

Date

Parent A Signature

Date

NOTE TO PARENTS: If you are submitting this application online, please note that by submitting your application online, The Parker H. Bainter Foundation will consider these forms signed and authorized.

Could you please send a picture of your child to The Parker H. Bainter Foundation?

Upload Photo

Does The Parker H. Bainter Foundation have your permission:

To use any information provided in this application or information discussed throughout the exploratory process as a means to determine whether The Parker H. Bainter Foundation will support your family at this time.

To use parent’s first names, children’s first names, the experiences/situations described within the application and/or any photographs taken by The Parker H. Bainter Foundation or provided by the applicant for promotional pieces published by The Parker H. Bainter Foundation.

Do you agree to write a letter of acknowledgement to The Parker H. Bainter Foundation if we are able to assist you and your family through this difficult time?

Please sign below if you release The Parker H. Bainter Foundation and its affiliates from any and all claims for damages, slander, invasion of privacy and/or any other claims resulting from or based on the use of your name(s), photograph(s) and/or testimonial(s).

I hereby represent that I am of full legal age and have every right to contract in the above regard. I hereby represent that this Release Form and Authorization has been fully explained to me and I fully understand the Application for Funding and Support and the Release Form.

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Parent A Signature

Please type full legal name.

Date

Parent A Signature

Please type full legal name.

Date

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The Parker H. Bainter Foundation was established to help support families with children in the hospital and offset the expenses associated with having a child in the hospital.

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Contact

805.691.2757
parkerhbainterfoundation@gmail.com

Parker H Bainter Foundation | EIN 88-2291761