Family Assistance

Family Assistance Application

Kairi's Star Foundation helps families facing financial, geographic, and logistical barriers to accessing specialized medical care for their child. Please complete this application with as much information as possible. Submission of an application does not guarantee assistance; all requests are reviewed based on eligibility, verification, available funding, and current program capacity.

First name

Last name

Phone

Multi-line address

Country/Region

Address

City

Zip / Postal code

Relationship to Child

Child's First Name

Child's Last Name

Child's Date of Birth

Child's Diagnosis

Date of Diagnosis

Current Treating Medical Facility/Medical Team

Treating Physician/Medical Contact Name

Treating Physician/Medical Contact Phone Number

Treating Physician/Medical Contact email

How Urgent is This Request?

Immediate-Assistance Needed Within 24-48 Hours

Urgent-Assistance Needed Within 3-7 Days

Time-Sensitive-Assistance Needed Within 1-2 Weeks

Standard-Assistance Needed in More Than 2 Weeks

Does the Child Have a Passport?

Yes

Unknown

Do All Necessary Family Members Have Valid Passports?

Yes

Unknown

I Expedited Passport Assistance Needed?

Yes

Unknown

What Medical Verification Can You Provide?

Appointment Conformation

Hospital/Clinic Communication

Clinical-Trial/ Program Confirmation

Physician or Social-Worker Contact