Grant Assistance Request Form

Grant requests take approximately 7 to 10 days to process once the Small Miracles Foundation receives all required documentation. Please make sure all copies of bills, receipts.

Small Miracles Funds can be disbursed for any of the following expenses:

Medical Bills: Hospital bills, doctor bills, insurance premiums, deductibles, prescription and /or medical equipment, therapy, etc.

Medical-Related Expenses: Expenses related to the child’s medical treatment, such as travel expenses, lodging, food, childcare, respite care, etc…

Family Care: Housing, utility bills, etc.

1. Small Miracles Foundation Definitions:

A Patient is a child who is 17 years old or under, who is afflicted by any form of pediatric cancer.

A Family is the biological or adoptive parent(s) or legal guardian(s) of the patient who are facing financial hardship because of the patient’s illness.

A Small Miracles Grant is a gift of money that is to help pay for the uninsured medical expenses, special equipment, therapy, prescription drugs or health insur­ance premiums. Grants may pay, while the patient is undergoing treatment, transportation and lodging during away from home treatments. Grants may pay for utilities, basic phone coverage, mortgage, rental payments, or other items of support of general living conditions. In order to help as many families as possible the maximum grant to any one family unit will not exceed $1,000.00 in total.

2. Small Miracles Grant Requests:

In order to receive a Small Miracle Grant, in addition to the completion of the application, a completed Grant Request Form must be submitted and completed by a social worker and accompanied by copies of bill(s) and/or statements. All grants are at the sole discretion of the Board of directors of Small Miracles Foundation.

3. Medicaid, SSI, and State-funded Insurance Recipients:

Small Miracles Foundation will only dispense checks to the various service providers and will not dispense funds directly to a family. However, it is not the responsibil­ity of Small Miracle Foundation to monitor or protect your family’s status with Medicaid, SSI or any State- funded Insurance program.

4. Consent/Release of Small Miracle Foundation:

We agree to have our Child (Patient) and family involved in a Small Miracles Foundation Grant program. We freely receive Small Miracles financial support as a gift without expectation, demand or prom­ise of a specific dollar amount.

We consent to our Child’s Social Worker and/or Physi­cian disclosing information about our Child’s medical and financial need to Small Miracles Foundation. We understand and agree that Small Miracles Foundation acts only as a charitable donor. We do not hold the organization responsible for fund raising outcome. We accept and agree to follow the policies described herein

Based on my knowledge of the patient’s medical condi­tion and his/her family’s associated financial needs, I believe this family qualifies for support under the Small Miracles Foundation Program.

The following form MUST be filled out by the patient’s social worker or case worker.

Fields marked with an * are required

Please read the terms and conditions above. Then complete the application below as completely as possible.



Patient and Family Information:


Medical and Financial Needs:


Format for multiple checks:

This is for the social workers when there are multiple requests for one family.  We would appreciate if you could fill this out it streamlines the process.