Emergency Assistance Program | Rest Haven Children's Health Fund

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Children's Health Foundation - Admin Use Only
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Final Status
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Record
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Email/Letter Status
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Date Correspondence Sent
MM slash DD slash YYYY
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Outstanding Tasks
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Payment Method
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Description of Gift
This application was recently updated in May 2026. Please read carefully. Complete all required fields and be as specific as possible for a quicker review. Applications not meeting the requirements below or found on https://resthavenchf.org/eap/ will be automatically rejected.
Disclosure of Health-Related Information
By submitting this form on behalf of the child, you represent that you are authorized to provide the information included and that any disclosure of health-related information complies with applicable privacy laws, including HIPAA, and is limited to the purpose of processing this application.
Today's Date*
MM slash DD slash YYYY
Child's Information
One child per referral form.
Child's Name*
First Last
Child's Date of Birth:*
Month
Day
Year
County of Child's Permanent Residence*
Children's Health Foundation provides funding only to children ages 0-17 who permanently reside in San Diego County or Imperial County in the State of California. Please indicate in which county the child currently resides.
Parent(s) or Guardian(s) Information
First Parent or Guardian*
First Last
Second Parent or Guardian
First Last
Parent/Guardian Address*
Street Address Address Line 2 City State ZIP / Postal Code
Parent/Guardian Cell Phone:*
Parent/Guardian Alternate Phone:
Parent or Guardian Primary Email Address (required)*
All correspondence we send to the parent/guardian regarding donations for the child will be sent to this email address. Do not use social worker's or referring agency email. Failure to provide an active email address for parent/guardian will result in an automatic rejection.
Parent or Guardian Secondary Email Address (if any)
Child's Health Information and Reason for Request
Please be as specific as possible to avoid delays.
Medical Diagnosis:*
General Category of Request*
All requests must relate to the medical diagnosis described above and positively impact the child's health. Please review Types of Items Funded at https://resthavenchf.org/eap/
- Emergency Family Services
- Emergency Basic Needs
- Special Diet
- Adaptive Equipment
- Dental Treatment (must upload dental treatment plan)
- Cremation or Burial Assistance
- Glasses (preapproved through San Diego Unified School District)
For fetal death assistance, please provide gestational age in weeks:
Specific Request:*
Describe the item, equipment, treatment, etc., and any other details needed for us to make a determination as to this request. For burial or cremation assistance requests, please also provide date of death.
Reason for Request:*
Provide details regarding the family's circumstances, including siblings/others living in home, family dynamics, employment and financial status, extenuating circumstances that lends support to request, other funding resources pursued, how request will impact child’s health* and any other pertinent information to help in determination. *All requests must explain how this desired support relates to and will impact the child's health condition that you provided above. Failure to include this information will result in the rejection of your application.
List all other public or private resources that were exhausted prior to this request to Children's Health Foundation.*
Children's Health Foundation can provide funds for health-related services for children residing in San Diego and Imperial counties when no other funds are available. You must describe other resources (such as other agencies, nonprofits, or foundations) you have pursued in order to be considered for our assistance.
Total Amount Requested:*
(include tax & shipping, if applicable) Note: Funds are for future purposes only. We do not reimburse for funds already spent.
Supporting Documentation
Upload any supporting documentation (if any), such as an invoice, medical documentation, etc. here.
Max. file size: 50 MB.
Services Receiving
Tell us what services the patient and/or their family is currently receiving.
(only check those that apply)
Medi-Cal
- Medi-Cal
Type of Coverage:
Denti Cal
- Denti-Cal
Type of Coverage:
Private Medical Insurance
- Private Medical Insurance
Type of Coverage:
Private Dental Insurance
- Private Dental Insurance
Type of Coverage:
Other Health Coverage
- Other Health Coverage
Type of Coverage:
California Children’s Services
- California Children’s Services
Type of Coverage:
San Diego Regional Center
- San Diego Regional Center
Type of Coverage:
In Home Supportive Services
- In Home Supportive Services
Type of Coverage:
Vendor Information
Vendor:*
Note where item/service can be purchased.
Website
Vendor's Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Vendor's Contact Name:
Vendor's Email Address:
Vendor's Phone:
Information About Person Making the Referral
Unfortunately we cannot accept self referrals. All Emergency Assistance Applications must be made by a social worker, case worker, school administrator or counselor, or someone with similar professional credentials.
Person Making Referral*
First Last
Title:*
Full Name of Agency, Hospital, Nonprofit, School, etc.*
Mailing Address:*
Street Address Address Line 2 City State ZIP Code
Referring Person's Email Address:*
Phone:*
Additional Information (optional)
You can upload an image here if desired.
Accepted file types: jpg, jpeg, png, gif.

Children's Health Foundation - Admin Use Only

This application was recently updated in May 2026. Please read carefully. Complete all required fields and be as specific as possible for a quicker review. Applications not meeting the requirements below or found on https://resthavenchf.org/eap/ will be automatically rejected.

Disclosure of Health-Related Information

Child's Information

Parent(s) or Guardian(s) Information

Child's Health Information and Reason for Request

Services Receiving

Vendor Information

Information About Person Making the Referral

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