Assistance Application

Once we receive your application we will contact the fundraiser’s spokesperson and a meeting, either in-person or by telephone, will be scheduled with our Board to discuss the details of the planned fundraiser. Once the meeting has been completed, our Board will discuss your application and the ways in which we can be of assistance to you. If you would rather submit a paper application than an “on-line” application, please click here.

Applicant Name *
Applicant Name
Person completing this form.
Applicant Address
Applicant Address
Applicant Phone
Applicant Phone
Recipient or Family Contact Information
Recipient Name
Recipient Name
Recipient Address
Recipient Address
Recipient Phone
Recipient Phone
Details
Please provide an explanation of the community fundraiser being planned including, the title of the fundraiser, the date, the time and the place of the fundraiser. In addition, please provide a budget detailing the anticipated donations to be received and expenses that will be incurred in conducting the community fundraiser for which you will seek reimbursement, e.g. venue rental, event insurance or catering.
Please include the patient’s diagnosis, date of birth and date of diagnosis. In addition, please provide a detailed explanation of the purpose for which the community fundraiser is being held e.g. purchase of handicapped equipped van, home modifications for handicapped accessibility, uninsured medical and related expenses.
Lost income, unreimbursed medical expenses, extensive hospital stays, etc.