Apply for Assistance
Financial Grant Application

Application Form

To request assistance from Vaughn’s Wings of Hope (VWOH), please fill out this form and sign with your digital signature. You can apply for yourself or someone else, but the application must include all required information.

Unfortunately progress cannot be saved, so please have all your information ready when beginning the application process.

Tell us about the person that needs assistance.

Medical Information

Please choose a grant amount based on your needs. *

Treating Medical Professional Information


Please provide at least one reference. It's helpful if this person knows about you and your situation. Providing two references is preferred but not required in order to complete the application process.

2nd Reference (optional)

Terms, Conditions, & Signature

By signing this form with your digital signature you attest that you have a terminal illness or you are requesting for someone who has a terminal illness. You agree to be contacted regarding your application or if requesting for someone else, you agree that we may contact both of you. You agree to and give consent for us to contact your physician to verify your diagnosis and to contact any references you have listed. If you agree with these statements, click "Yes, I agree" to proceed or "No, I don't agree" to stop the application process. *

Digital Signature - to provide your electronic signature type your full name in the box below and select the date. *

Thank you! Your submission has been received!
For some reason you selected that you didn't agree with our terms and conditions. We apologize if something in this section didn't feel right for you. If you reached this page by mistake, please go back to the terms and conditions page and continue with signing the form. If you are having difficulties with this form, have additional questions or need to speak with us before moving forward, please contact us at, visit us on our website at or on Facebook at