Children's Mercy Kansas City -

Children’s Mercy Hospital Healthy Homes Repair Program Application

Mission

The Healthy Home Program is a nationally recognized program that provides unique, holistic, and comprehensive approaches to identify environmental exposures in homes and work with families to address those exposures through a low-cost action-oriented plan.

Key Healthy Homes Repair Program Enrollment for Grant Eligibility Requirements

You must live in a home with a child that is experiencing a medical or environmental issue or concern.

You must plan to live at that address for at least 12 months after participating in the Healthy Homes Program.

If applying for rental unit updates, agree to work with your landlord to complete the updates that are recommended by our team.

Have no pending legal issues with the home contract/landlord agreement.

Agree to the Assessment Agreement terms (Redcap Survey will be emailed to you by Community Health Coordinator).

Agree to the best of your ability to provide necessary documentation for income verification below.

Work with the Children’s Mercy Healthy Homes team toward addressing concerns for the health of your home and family through education about the Healthy Homes framework and by identifying opportunities through a home assessment and answering online surveys with health and home related questions.

Submit income documents to verify that household meets income requirements (adjusted for family size).

Today's Date

Responsible Party:

The "Responsible Party" is the patient or patient’s legal guardian who is financially responsible for services provided by Children’s Mercy.

Last Name *

First Name *

Middle Name

Date of Birth *

Primary Phone *

Email *

Home Address *

City *

State *

Zip *

Responsible Party Approximate Combined Annual Income: *

Patient Information

Patient Last Name *

Patient First Name *

Patient Middle Name

Patient Date of Birth *

Please List All Persons In Your Household Below (including Responsible Party(ies) *

Last Name

First Name

Date of Birth

Relationship to Patient(s)

Last Name

First Name

Date of Birth

Relationship to Patient(s)

Last Name

First Name

Date of Birth

Relationship to Patient(s)

Last Name

First Name

Date of Birth

Relationship to Patient(s)

Last Name

First Name

Date of Birth

Relationship to Patient(s)

Last Name

First Name

Date of Birth

Relationship to Patient(s)

Last Name

First Name

Date of Birth

Relationship to Patient(s)

Last Name

First Name

Date of Birth

Relationship to Patient(s)

Last Name

First Name

Date of Birth

Relationship to Patient(s)

Please submit all documents that are appropriate for your household to apply for the Healthy Homes and Lead Grant:

1 month of Paychecks (for all working adults).

2 months of Banks statements for all people over 18 that are working, (accounts that income are deposited into).

Copy of Home Deed (If you own your home) or signed Tenant Enrollment Form (if renting).

Tax returns for unemployed household members over 18.

Attachments

For further questions about submitting documents or other assistance or information about our program:

Call: 816-302-8565

Email: CEHHELP@cmh.edu

For additional information about the US Department of Housing and Urban Development Program or Grant please visit

https://www.hud.gov

Signature of Patient/Parent/Legal Guardian *

Printed Name

I acknowledge the above represents my electronic signature.

Date

Children’s Mercy Hospital Healthy Homes Repair Program Application

Mission

The Healthy Home Program is a nationally recognized program that provides unique, holistic, and comprehensive approaches to identify environmental exposures in homes and work with families to address those exposures through a low-cost action-oriented plan.

Responsible Party:

Patient Information

Please List All Persons In Your Household Below (including Responsible Party(ies) *

Please submit all documents that are appropriate for your household to apply for the Healthy Homes and Lead Grant:

For further questions about submitting documents or other assistance or information about our program:

Call: 816-302-8565

Email: CEHHELP@cmh.edu

For additional information about the US Department of Housing and Urban Development Program or Grant please visit

https://www.hud.gov

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