MRKKC_application-form

Msgr. Russ Kohler Children’s Cancer Endowment Fund Application for Financial Assistance

* = Required Field; Please complete all sections of this Application.

Applicant / Parent / Guardian Information

Full Name*

Street Address*

City*

Michigan

Zip Code*

Email*

Phone Number

Relationship to Patient*

Mother Father Grandparent Other

Please describe your relationship to the Patient

Patient Information

Full Name*

Date of Birth*

Street Address*

Same as Applicant's Different from Applicant's

Street Address*

City*

Michigan

Zip Code*

Email (Optional)

Phone Number (Optional)

List of Other Household Members

(Up to 4, if more than 4, please list additional in your Financial Situation Summary Letter)

Name

Date of Birth

Relationship to Patient

Name

Date of Birth

Relationship to Patient

Name

Date of Birth

Relationship to Patient

Name

Date of Birth

Relationship to Patient

Medical Information

Hospital

Name of Physician*

Address of Physician*

Phone Number of Physician*

Name of Social Worker

Address of Social Worker

Phone Number of Social Worker

Typer of Cancer*

Stage

Date of Diagnosis*

Is Patient in Active Treatment?*

Yes No

Type of Treatment

Frequency of Treatment

Financial Position

Income*

Assistance

Expenses*

Other Financial Information

Savings / Investments

Credit Card Debt

Other Liabilities

Financial Assistance

Expenditures to be Covered

Additional Documentation

Please see above for list of additional documentation required to be submitted with the Application form.

Please mail documentation to The Msgr. Russ Kohler Children’s Cancer Endowment Fund, c/o STAT Patients Family Services, P.O. Box 63, Newport, MI 48166. Be sure to include the Patient’s name and the Applicant’s name with your submission.

Upload digital photo of Patient

Representation of Applicant

I certify that the information provided is true and correct as of the date opposite my signature below. Any intentional misrepresentation of the information contained in this Application will result in the loss of current and future assistance from the Endowment Fund and may result in civil and/or criminal liability.

The Applicant hereby releases the Endowment Fund from any and all liability, which may arise from the sharing of this information with third parties.

The Applicant hereby grants permission to the Endowment Fund to publish in print and/or electronic format, the likeness or image of myself, child and other family members. The Applicant releases all claims against the Endowment Fund with respect to copyright ownership and publication including any claim for compensation related to the use of the materials.

For the purpose of procuring assistance from the Endowment Fund from time to time, the Applicant will furnish the foregoing information as a true and accurate statement of his/her circumstances, including health, finances and any other information contained in this Application. Authorization is hereby given to the Endowment Fund to verify in any manner it deems appropriate any and all items indicated on this statement. The undersigned also agrees to notify the Endowment Fund immediately in writing of any significant change in any of the foregoing information.

Name of Applicant