Briefly explain your situation (please print)
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________

Purpose funds will be used for (please print)
____________________________________________________________
____________________________________________________________
____________________________________________________________

Requested amount:  $ ___________________

If for payment of doctor, hospital, prescriptions, therapy, or other institution

Check should be made payable to _____________________________________

Mailing address:    __________________________________________________
                                __________________________________________________
                                __________________________________________________

                             Agreement and Release of Responsibility

You are required to read the Guidelines for Application and Privacy Policy.

I have read and do completely understand the Guidelines for Application and Privacy Policy
to Wishes and Rainbows for assistance.

Under no circumstance is Wishes and Rainbows responsible for any incidents or accidents
that may occur during the time of assistance,  prior to or following the situation requesting assistance.

Signature: ______________________________________________



Application for Assistance from Wishes and Rainbows

Name: ___________________________________________ Date: _________2011

Address: ______________________________________ Apt# ____

City_________________________________  State________  Zip __________

Home Phone:  (       )_______________Work Phone: (       )________________

Cell Phone: (       )__________________

E-Mail address: _________________________________________________

Person for whom this application is being made:__________________________

Relationship: ___________________________________________
________________________________________________________________

Monthly Net Income (Include food stamps, child support, and any medicaid assistance)                                                                                          
                                                                     _____________.____                                                                                                                                                
Checking Account  yes  no         Balance  ___________.______ 
Savings Account  yes  no           Balance ___________.______

No. of dependents: ___________  (Please include self and spouse)
Please list everyone in the household below.






Mortgage or Rent   ______________.____
Home Owners / Renters Insurance     ______________.____
Electric     _____________.____
Gas           ______________.____
Water        ______________.____
Phone (basic service only)   ______________.____
Car Payment   ______________.____
Gas / Car fees              ______________.____
Auto Insurance        ______________.____
Clothing Allowance ($10 per person allowed) ______________.____
Entertainment       25.00
Medical Insurance  ______________.____
Prescriptions   ______________.____
Other Medical  ______________.____
Food, Cleaning Supplies and Toiletries   ______________.____
School Expenses (Books and Supplies)  ______________.____
Other expenses (explain)     ______________.____
______________________________________
Total Expenditures ______________.____

                                          Remaining Balance:     $

Release of Information (click here & print out)

Privacy Policy

DID YOU REMEMBER ???

  • To sign the "Release of Responsibility" form
  • Include ALL required verification information for your particular request
  • Print or type clearly so your application can be read accurately
This page was last updated: July 14, 2011
Application will print out on more than one page. 
We will also need for anyone assisted to fill out "Feedback" form located on the home page. Many times,  these type of questions are asked from us on our applications for grants.


Fax App to 812-903-0189