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Who We Help
Board of Directors
Financial Assistance Online Form
Name of child needing treatment:
Name of parent(s):
Are you the legal guardian?
District of Columbia
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
Please identify the medical condition and a brief description of medical treatment needed:
Is this treatment prescribed by a physician?
Name of physician:
Please provide the name of the treatment facility, location and attending physician of where your child will receive medical care:
Ex. Deaconess Hospital, Spokane, WA, Dr. Smith
Dates of medical treatment:
Number of Days Your Child Will Need Treatment
Please check the types of travel expenses you will be requesting for reimbursement:
Check all that apply.
If you selected Transportation, please indicate type(s):
If selected Lodging, how many nights stay?
Please estimate the total amount of reimbursement requested:
The total amount of reimbursement must be filled in to complete your application.
Is your child covered under private insurance/Healthy MT Kids/Medicaid?
Medicaid and HMK offer travel reimbursement. Please provide the amount. (This does not disqualify applicants)
Name of Insurance:
Medicaid/HMK will reimburse for some transportation costs. For more info, call Medicaid Transportation 1-800-292-7114.
Have you received or applied for other financial assistance for your child's treatment costs?
Has child or any other family member received funding from For the Children, Inc. before?
If so, please list the amount and date received:
Please list how many people living in your household and ages of each person:
Annual Household Income:
You may be requested to provide verification of employment and income for application approval.
Place of employment per person:
Please list other sources of income such as Child Support, SSI, and Disability:
Do you have other resources to assist your child during this difficult time, such as church, extended family members, etc?
Is this a one-time request or will your child need more treatment in the future?
PLEASE FILL OUT THE CONSENTS BELOW TO COMPLETE YOUR APPLICATION
Verification of Information
I hereby state that the above information is correct and that there are no other sources of funding for the expenses for which I am requesting reimbursement. In addition, I agree to abide by all guidelines as required by For the Children, Inc. to receive financial assistance. I understand that failure to do so may result in my forfeit to obtain funding.
Name of Applicant:
Please read the above statement and enter your name above.
Release of Medical and Insurance Record
I authorize the release of medical and insurance record to For the Children, Inc. for the purpose of certification of need. This release expires within one year of authorization.
Name of Parent/Legal Guardian:
Once you read and agree to the "Release of Medical and Insurance Record" please type in full name.
Consent for Testimonial
Whitefish Winter Classic is the annual fundraiser for our organization. Many times, there is a need to have testimonials from our recipients to help market our mission. If you are willing to participate in helping us by providing a testimonial, please check the box below.
Please contact me to provide a testimonial for the Whitefish Winter Classic.
Not at this time.
Please check the box below when you have read the above "Verification of Information" and"Release of Medical and Insurance Record".
I have read the "Verification of Information" and "Release of Medical and Insurance Record".