APPLY | Blossoming Butterfly Inc.

BLOSSOMING BUTTERFLY

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Blossoming Butterfly Assistance Program

Please complete all required fields. Submission of this application does not guarantee assistance.

First Name

Last Name

Emergency Contact information

Household Income Information

Please select your household income range.

$0 – $25,000

$50,000 – $75,000

$25,000 – $50,000

75,000 and above

Required Documentation

Diagnosis documentation

Upload supported file (Max 15MB)

(physician’s note required)

Proof of financial need

Upload supported file (Max 15MB)

(income verification or assistance statements)

Proof of residency

Upload supported file (Max 15MB)

(lease, mortgage statement, or recent utility bill)

Requested Assistance

Applicant Certification and Acknowledgment

I certify that the information provided in this application is true, complete, and accurate to the best of my knowledge. I understand that submission of this application does not guarantee assistance and is subject to eligibility requirements, available funding, and program guidelines established by Blossoming Butterfly, Inc.

Consent to Verify Information

I authorize Blossoming Butterfly, Inc. to verify the information provided in this application, including documentation related to diagnosis, financial need, and residency, for the sole purpose of determining eligibility for assistance.

Privacy and Confidentiality Notice

Blossoming Butterfly, Inc. respects your privacy and is committed to protecting your personal information. Information collected through this application will be used solely for program administration, eligibility determination, and reporting requirements as permitted by law.

Health Information Acknowledgment

I understand that any health-related information submitted is provided voluntarily and solely for the purpose of determining eligibility for assistance. Blossoming Butterfly, Inc. is not a healthcare provider and does not provide medical treatment. Medical documentation will be handled confidentially and accessed only by authorized personnel.

I have read and understand the Applicant Certification, Consent to Verify Information, Privacy and Confidentiality Notice, and Health Information Acknowledgment, and I agree to the terms stated above.

Thank you for submitting your application. A member of our team will review your information and contact you during business hours if additional documentation is needed.