lendahand

LEND A HAND UP FUNDRAISER REQUEST

PART 2 - FAMILY SIGN OFF

Consent and Information About Crisis

To be completed by individual or parent/guardian

receiving help.
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.
- Information about the child or adult currently experiencing a debilitating health issue, traumatic event, or loss of life resulting in substantial out-of-pocket expenses of $5,000 or more.
- Documents verifying local residency, name, age (driver's license or birth certificate)
- Documents validating the medical condition (note from doctor's office), traumatic event or loss of life.
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: jpeinovich@dakmed.org or 701-356-2661. Fax: 701-271-0408.
Name*

First NameLast Name

Section 2A:

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.
Recipient Name*

First NameLast Name
Age*
Gender*

MaleFemale
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
County Residency*

Cass (ND)Clay (MN)Becker (MN)
Number of years living in current county:*
Cell Phone*
Other Phone
E-mail*
Name of Employer*
N/A if not employed
Names of other individuals living in the same household; if children, include their ages

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.
Due to medical challenges or recent physical trauma, do you expect your out of pocket expenses and/or your loss of income to exceed $5,000?*

YesNo
Explain:*

0/500

Out-of-Pocket Expenses

	Out-of-Pocket Expenses Past 12 Months	Estimated Out-of-Pocket Upcoming 12 Months
Medical Care (Provider, Lab, Radiology, Inpatient/Hospital)
Prescriptions/ Equipment/Supplies
Health Insurance - cost (if any) you pay to maintain coverage (Your premium/liability expense per month x number of months)
Travel/Gas (Based on $0.25/mile x number of miles x number of trips)
Lodging/Food (If you receive medical care out of area, estimate costs based on $125/person or $200/family x number of days there
Enter the total of the above five rows
(Optional) - Non-Medical Expenses Increasing Financial Hardship Due to Medical Condition and Lost Wages. Example: mortgage/rent, food, daycare, auto, etc.