Application for Funding and Support

Social Worker and/or Child Life Specialist Portion

Helping families manage life while they wait on their miracle.
Miracle for Mateo supports families with a chronically or terminally ill child, who are struggling financially due to their child's life threatening illness and lengthy hospitalization, by "helping families manage life while they wait on their miracle."
Miracle for Mateo provides financial support for families with dependent children who: have complex congenital heart disease or another life threatening illness, and are struggling through a lengthy hospitalization of greater than 30 days, are waiting for transplant, or who are living at home on hospice care. Miracle for Mateo accepts applications monthly and reviews completed applications on the third Tuesday of each month. Miracle for Mateo offers support to families who have a child receiving medical treatment in the Tri-State area (NJ, DE and PA) by providing funds for: hospital cafeteria meals, utility bills, living expenses, gas and travel expenses, and/or a wristband bracelet fundraiser.
 
Completed applications will be reviewed on a monthly basis at the Miracle for Mateo Board Meeting on the third Tuesday of each month. 
 
Please complete this portion so that Miracle for Mateo Non-Profit Organization is able to gain an understanding of the child’s current diagnosis and prognosis, as well as how the child’s illness and/or hospitalization have impacted the family.

Please either submit online, or return to Miracle for Mateo, PO Box 101, Shiloh, NJ 08353. If you have difficulty submitting your application online, applications may also be scanned and emailed to miracleformateo@yahoo.com. Thank you.      

 
Today’s Date*
Hospital*
Name of Social Worker*
Address*
Phone Number*
Email*
Child’s Name*
Date of Admission*
Health Insurance Provider*
Date of Birth*
Child’s Primary Medical Diagnosis*
Date of Diagnosis*
Child’s Primary Physician*
Is child currently in a private room or in a pod?*Private Room   Pod   
Chaplain*
Please describe the child’s treatment up to this date and his or her current status.*
Please explain how the family has been affected by this situation.*
Social Worker’s or Specialist’s Printed Name*
Social Worker’s or Specialist’s Signature*
Date*


Parent Portion Of Application

Release Form