Giving Tree 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. Approved applicants will be contacted with a date and time to pick up their gifts

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.

1. A valid photo ID of the applicant
2. Proof of household income (most recent pay stub for all working members of the household)
3. Proof of residence (most recent utility bill or bank statement with current address)
4. 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)
(i.e, specific toy or game)
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