Apply for Assistance

Please keep in mind that we are not able to provide assistance to all individuals who apply for financial assistance. In the event that we aren’t able to help you, we will do our best to refer you to other charitable organizations who may have the resources you need. In order for us to learn more about your life and your circumstances so that we may assess our ability to assist you, please complete this application form.Our Board of Directors will review all requests and will determine Rebekah’s Angels ability to fulfill yours. We will make every effort to inform you of our decision whether or not to move forward as soon as possible.

Parent / Legal Guardian Information

Child Eligibility

Child’s Information

Child’s Physician Information

Additional Questions

Authorization

Thank you!
Your assistance application has been submitted.
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