Request Assistance Form
Request Form for assistance
Sign in to Google to save your progress. Learn more
Email *
Childs Full Name *
Have we helped your child before? *
We have two methods of funding.  Which one would you like to use.
Clear selection
What is your Cash App "$CASHTAG"   *Please double check this information!  Cash App must match your drivers license information.  
Male or Female *
Child's Date of Birth (Ages must be Birth-18 years old) *
MM
/
DD
/
YYYY
Is Child on Medicaid *
Home Address (Notes:This is where we mail funds to, has to match Drivers license, Also Please do not use Ronald McDonald address as a house address.) *
City *
State *
Zip Code *
County  (Must live in one of these counties to qualify for assistances.) *
Are you both the Child's Legal Guardian and Custodial Parent? *
Legal Guardian/Parents Name:
Cell Phone *
Is your child currently in a NICU (Neonatal Intensive Care Unit)?   *
Next
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy