LEND A HAND UP FUNDRAISER REQUEST
PART 2 - FAMILY SIGN OFF
Consent and Information About Medical Challenges
Should be completed by individual or parent/guardian
Please review the fundraiser and boost criteria HERE or find it on the "Start a Fundraiser" page at LendAHandUp.org before proceeding with the Lend A Hand Up Request.
Have the following information available to complete the application. Please forward documentation to the Lend A Hand Up office.
If you'd prefer to print and complete a request on paper, do not use this form; instead use the attached printable PDF request.
To forward documentation or if you have questions about required information and guidelines, please contact the program office: email@example.com or 701-356-2661. Fax: 701-271-0408.
Information about child or adult currently experiencing a debilitating illness or injury, or who recently suffered a traumatic event resulting in substantial out-of-pocket expenses of $5,000 or more.
Section 2B: Medical Information
Section 2C: Out of Pocket Expenses (NOT Covered by Insurance)
Out of pocket expenses include expenses NOT covered by insurance or other programs and include medical bills as well as prescriptions, supplies, mobility devices, home adaptations, gas and lodging (if seeking medical care out of area), and other nutritional/health necessities.
Section 2D: Recipient Signature
REMINDER: Don't forget to mail, email, drop off or fax:
Please ensure that the Part 1 - Request for Boost Funding has been completed by a committed and caring person willing to serve as the champion for this fundraiser (should be someone outside of your/recipient's household).
If a Lend A Hand Up representative has not confirmed that your application was received within 3 days of submission, please contact the program office.
Staff:Jeana Peinovich, Lend A Hand Up Director(701) 356-2661, firstname.lastname@example.orgHeather Hanson, Lend A Hand Up Coordinator(701) 356-3138, email@example.com
Address:4141 28th Ave S, Fargo, ND 58104