Bayou City Breastfeeding 2021 Grant Application Application for the 2021 Bayou City Breastfeeding Grant/Scholarship fund Grant Program Overview Breastfeeding plays a critical role in infant and maternal health and wellbeing. As an organization, we believe that all families should have access to qualified resources during their breastfeeding journey. And while insurance is supposed to provide coverage for these services, often families find that coverage is limited, or they may not even have access to insurance. In 2020, our organization donated $19,980 of lactation support services to families in need. For 2021, we are establishing a structured grant program with an initial budget $12,000 ($1,000/month). Additional funding may be made available quarterly. These funds will be used to help offset a percentage of the cost of lactation support for families in need. Grant Program Guidelines Applications for the grant program will be accepted from any family with financial need that lacks insurance coverage for our services To apply for the program, simply fill out the form below Approvals are made on a first-come, first-served basis, until funds are exhausted. Approvals will limited by available funding. Once approved, the grant will offset part of the visit cost, but families are expected to pay as much as they can towards the visit fee. This allows us to help more families. You will not be required to show verification of income. However, larger grant amounts will result in fewer famlies being helped, so we ask that each family pay the highest fee they can afford and choose office visits over home visits. Grant funds may not be used for travel or cancellation fees. Grant funds may be used towards the following types of visits: prenatal visits, post-partum visits, bottle feeding visits, pumping visits, and Frenotomy procedure support. We encourage applicants to choose either in-office or virtual visits. Applicants requesting an in-home visit will be required to pay the $60 travel fee. In addition, applicants must provide a reason that they are unable to have an in-office visit. Families are required to provide a valid credit card upon scheduling their appointment, and this card will be used to pay the family portion of the visit fee at time of service. Appointments made under this program are subject to our standard cancellation policy. If the appointment is cancelled with less than 24 hour notice, a $50 fee will be charged. If the client does not contact us to cancel the appointment and misses the appointment (no show), they will be charged for the full consultation fee, and will no longer be elligable to use grant funds. Families will be approved for two visits that must be used within 30 days of approval. Additional visits must be pre-approved on a case-by-case basis by Bayou City Breastfeeding to qualify for using additional grant funds. Approval for additional visits may be limited by available funding. Bayou City Breastfeeding reserves the right to submit an insurance claim for the visit. If the family receives insurance reimbursement for services, these funds will be used to repay the grant, up to the maximum amount provided by the grant for the visit. Funding for the BCB Grant Program Each month, Bayou City Breastfeeding will add $1,000 to the grant fund (total of $12,000 for the year). Additional funding may be made available quarterly by Bayou City Breastfeeding. Members of the community are invited to donate to the program, but donations are not tax deductible. At the end of the year, a report will be provided to all donors and recipients. If you would like to donate to the grant program, please use this link: Donate now Grant ApplicationParent's Name* First Last Parent's Email Address* PhoneParent's Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Parent's Insurance Provider* Child's Insurance Provider* Please tell us about your situation and why you are applying for the grant:In order to serve the greatest number of families, we do ask that all families pay as much of the visit fee as they can afford per visit. Our discounted timely payment (cash pay) rates for visits are as follows: Prenatal (Office) Visit: $150.00 Initial Postpartum (Office) Visit: $195 Follow up (Office) Visit: $165 Frenotomy Procedure Support Visit: $165 Virtual Visit: $100 We also strongly encourage applicants to choose in office or virtual visits, as the Grant funds may not be used to pay travel fees. Grant requests for in-home visits must show that the applicant is unable to have an in-office visit(for example, lacking transportation). Additionally, if requesting in-home visit, the applicant will be responsible for paying the additional $60 travel fee for each home visit in advance of the visit. Requested Grant Amount*$110 Grant (Family pays $125 per visit)$160 Grant (Family pays $100 per visit)$210 Grant (Family pays $75 per visit)$240 Grant (Famly pays $60 per visit)$260 Grant (Family pays $50 per visit)$280 Grant (Famly pays $40 per visit)$300 Grant (Famly pays $30 per visit)Type of Visit Requested*Type of Visit RequestedOffice VisitVirtual VisitHome VisitReason for requesting a home visitPlease tell us why you are requesting a home visit. Home visits will incur an additional $60 per-visit fee.How did you hear about us? Use of Grant Funds* I understand that grant funds may not be used for home visit travel fees or cancellation fees.Consent to contact* I give consent for Bayou City Breastfeeding to contact me regarding my Grant Application.EmailThis field is for validation purposes and should be left unchanged.