Lighthouse of Hope Fund - Application Patient's Name* Patient's Age Hospice Organization* Hospice Contact Name Hospice Contact Title Contact Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Contact Phone*Contact Email Address* Experience InformationExperience Requested (please be specific and include why this should be granted)*Participants in the Experience (spouse, children, caregiver, etc.)Names - Ages - RelationshipCost of the Experience (please include an itemized budget, total not to exceed $1,500)*Statement of Need and Financial Status* I certify that the applicant has a life expectancy of less than twelve months and has no other means by which to fund this experience. I have discussed this experience with the applicant and have deemed it safe and reasonable that his/her experience is granted. I acknowledge that any funds not used for this specific experience, used for unapproved costs, or cannot be accounted for in receipts must be returned to NHF. Financial reporting must be submitted within one month after the experience occurs. I understand that if I do not comply with these financial reporting requirements that my hospice organization will no longer be eligible to receive grants from the Lighthouse of Hope Fund. Hospice Representative* Date* MM slash DD slash YYYY
