Financial Aid Application Form

Simply A Miracle currently offers financial aid to families who have experienced the loss of an infant (pregnancy through 1 year old). Aid is paid directly to service providers (doctors, hospitals, therapists, funeral homes, etc.). We are unable to pay for expenses that are not directly loss-related, such as utility bills, rent, car payments, groceries, insurance, etc. Financial aid is given based on circumstance and financial need, as determined by the information submitted during this application process. Aid is also dependent on availability of funds. Simply A Miracle does not guarantee payment of financial aid to any applicant, and reserves the right to decline services to any applicant without explanation.

Simply A Miracle is a 501(c)(3) non-profit organization, and all Simply A Miracle Financial Aid grants are funded 100% by donors. In order to steward their donations with care, we collect information to verify the circumstances and financial needs of each applicant. If you are uncomfortable answering any of the questions on the Financial Aid Application Form, please contact us at simplyamiraclecompany@gmail.com.

After reviewing your application we will contact you regarding our decision, how much we are able to pay, and how and when we will be paying providers in your behalf.

Upload files for any loss related costs you are requesting assistance with (i.e. mortuary invoice, medical bill, cemetery invoice). These files need to include the account holder information/bill pay information in order for us to pay providers directly.

We realize that many of these questions are sensitive. We assure that we will treat your answers with respect and privacy. Any private information you provide will only be used to pay providers on your behalf, and will not be shared.

Please answer as completely as you can. This will allow us to help in the way that will make the biggest difference so you can focus as much as possible on grieving, loving, remembering, and healing.

First Name *

Last Name *

Email *

Phone *

Address *

City *

State *

Postal code *

Date of birth *

Spouse/Partner Name

Baby Name

Child's Birth and Death Date (date of delivery for miscarriage or stillbirth) *

Approximate dates for any other care received by mom or baby *

Location or Hospital of child's birth and death *

Approximate length of hospital stays for mother and/or child *

Did your child spend any time in the NICU?

Yes

Any emergency transportation mother and/or child received

Are you insured? *

Yes

Have you spoken with your insurance representative? *

Yes

Have you received any other financial assistance, including financial aid from your medical provider? Please include links to any fundraisers/gofundme sites set up for you.

Please provide a short paragraph or two about you and your child's story and circumstances. *

Have you received all bills for the mother and/or child's care? *

Yes

Have any related bills gone to collections? *

Yes

Have you or do you plan to receive any mental health counseling or support? *

Yes, I plan to

Yes, I already have

No, I don't plan to

Unsure

Have you or do you plan to pay for any mortuary services for the child? *

Yes

Unsure

Have you or do you plan to purchase a burial plot, urn, and/or headstone for the child? *

Yes, I already have

Yes, I plan to

No, I don't plan to

Unsure

Have you received any bereavement or parental leave? (for the mother and/or spouse or partner?) *

Yes

Have you had previous losses? If so, when?

What are the ages of any living children you have?

Please upload any bills or invoices for which you are requesting assistance.

If you are requesting help making a payment to a specific provider (i.e. funeral home, therapist, cemetery, etc.) and you do not have a bill with payment instructions, please list the provider's name and contact information here.

If there is anything else you'd like us to know, or any other relevant information, please add it here.

If any of your information (last name, address, phone number, etc.) has changed since you received care, please let us know.

Referral Source *

By filling out this form, you will automatically be added to our general mailing list. You can unsubscribe at any time.

We know you have a million things coming at you every day. Don't worry! We won't be spammy. You can expect to hear from us by email about once a month, and maybe a few extra times a year for big news or special occasions. We'll save the letters in your mailbox for extra special times!

We'd also love to connect with you on Facebook or Instagram.

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Privacy Statement

We value your privacy and are committed to protecting your personal information. We do not sell, rent, or trade your personal information with third parties. Your data will be kept confidential and will only be shared with relevant staff members within our organization as needed.

If you have any questions or concerns about our privacy practices, please contact us at info@simplyamiracle.com.