Request Assistance Form

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Request Form for assistance

Email *

Childs Full Name *

Have we helped your child before? *

Yes

I have another child that has received assistance before.

We have two methods of funding. Which one would you like to use.

Check (Check with be mailed to your home address and made out to the Legal Guardian/Parents Name on this form.)

Cash App ( Note: We are excited to offer this option for funding. We want to stress to you that this is a trial and we may not implement this as a long term option.)

Clear selection

What is your Cash App "$CASHTAG" *Please double check this information! Cash App must match your drivers license information.

Male or Female *

Female

Male

Child's Date of Birth (Ages must be Birth-18 years old) *

YYYY

Is Child on Medicaid *

Yes

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? *

Yes

Other

Social Worker

Legal Guardian/Parents Name:

Cell Phone *

Is your child currently in a NICU (Neonatal Intensive Care Unit)? *

Yes

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