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Feminist Health Fund Application Request
The Feminist Health Fund is a non-profit group that provides assistance to women for health-related expenses during times of financial hardship. Please use this application to make a financial assistance request. All other inquiries please contact us at
info@feministhealthfund.org
.
If you need assistance filling out this form, please give us a call at (937)767-8949.
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Email
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Your email
Name
*
Your answer
Date of Birth
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Your answer
Street Address
*
Your answer
Phone Number
*
Your answer
Please briefly explain the medical expense you need help with.
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Your answer
How much money in assistance are you seeking? (approximate)
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Your answer
Please briefly explain your current financial situation.
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Your answer
How did you hear about the Feminist Health Fund?
*
a friend/family member
online
social media
health services in Greene County
Other:
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