Individual Recipient Application
The application deadline for the 2018 dance has now passed. Any applications received will be saved for the 2019 dance.

All information must be filled out completely for the application to be accepted.

The information provided is strictly confidential and is for the use of the South High Marathon Dance only. The SHMD Committee will meet at the beginning of January to review all applications. Any application received after January 2, 2019 will be placed on file for consideration during the review process the following year. Applications will be considered incomplete and will not be reviewed unless all requested information is provided.

Recipient Information
All information in this section must be completed. This application will not be reviewed if all information is not filled in. Please refer to the recipient when completing this section of the application.
Recipient's Name *
Your answer
Street Address *
Your answer
City *
Your answer
State *
Your answer
Zip Code *
Your answer
Recipient's Home Phone *
Your answer
Other Phone Number
Your answer
Recipient Email Address *
Your answer
Recipient's Date of Birth *
Your answer
If under 18, name of parent or guardian
Your answer
Connection to South Glens Falls *
(A connection to SGF is not mandatory for consideration.)
Required
Medical Information
Diagnosis *
Your answer
Date of Diagnosis *
Your answer
Is the potential recipient currently under medical care? *
Is the potential recipient in active treatment? *
Name of healthcare provider *
Your answer
Health Insurance Information
Please indicate type of insurance. *
(Check all that apply.)
Required
Are prescription drugs covered? *
Household Financial Information
Is the potential recipient currently employed? *
Number of People in Household *
Your answer
Family Income Sources *
(Check all that apply.)
Required
Total Annual Family Income *
Your answer
Amount paid each month in copayments *
(As they relate to the potential recipient.)
Your answer
Amount paid each month in medications *
(As they relate to the potential recipient.)
Your answer
Amount paid each month in travel expenses *
(As they relate to the potential recipient.)
Your answer
Other expenses *
(As they relate to the potential recipient. Please include an explanation of other expenses.)
Your answer
Financial Assistance Needs
Amount Requested *
(Please write a dollar amount and be as precise as possible - DO NOT write the words "any amount")
Your answer
Has the potential recipient been a recipient of the South High Marathon Dance in the past? *
Describe the potential recipient's situation and how specifically a Marathon Dance contribution would be used to benefit this individual. *
Your answer
Information on the Person Making the Nomination
Please refer to the person making the nomination when completing this section of the application. Any questions about the application will be directed to this phone number and/or email address.
Name *
Your answer
Phone Number *
Your answer
Alternate Phone Number
Your answer
Email Address
Your answer
Relationship to Potential Recipient *
Your answer
Connection to South Glens Falls *
(A connection to SGF is not mandatory for consideration.)
Required
To view your confirmation, please scroll to the top of the page after submitting your application.
Your answer
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