Kerrington’s Heart Christmas Giving Application

This application for Christmas assistance may be submitted for any child who is under the age of 18, suffering from a congenital heart defect(CHD), and whose permanent residence is in the state of Kentucky.  Siblings of a child suffering from CHD are also eligible under the same application. Eligible families must be experiencing a financial hardship as a result of expenses incurred within the last 6 months related to travel, lodging, hospitalization, or other expenses associated with the child's medical diagnosis that are not covered by insurance.

Application Deadline - November 16 Pickup Date - December 21

PLEASE COMPLETE ENTIRE APPLICATION

You will need to email the following documents to info@kerringtonsheart.org in addition to completing the information below to be considered. Incomplete applications will not be considered.

All applicants must have the following information:

  1. A valid Kentucky State Drivers License of the applicant

  2. Verification of all members of the household, including Birth Certificates or Immunization Records of children ages 0-17

  3. Proof of all monthly income and sour e of income from all household members. (Paycheck stubs, a letter of verification from KTAP, Social Security, SSI, proofs of child support)

  4. Proof of rent, mortgage or subsidized housing.

  5. Proof of other expenses (car, loans, credit cards)

  6. All current utility statements (electric, water, gas, cable, phone, etc.)

  7. Proof of housing expense (most recent mortgage or rent statement)

Applicant Name *
Applicant Name
Phone *
Phone
Applicant's Address *
Applicant's Address
Child 1 (CHD Child)
Child 1 Name:
Child 1 Name:
CHD Child Date of Birth *
CHD Child Date of Birth
When was their last hospitalization? *
When was their last hospitalization?
(i.e. type of clothing or other need)
Child 2 (Sibling)
Child 2 Name:
Child 2 Name:
Sibling Date of Birth
Sibling Date of Birth
Child 3 (Sibling)
Child 3 Name:
Child 3 Name:
Child 3 Date of Birth
Child 3 Date of Birth
Child 4 (Sibling)
Child 4 Name:
Child 4 Name:
Child 4 Date of Birth
Child 4 Date of Birth