Pay-it-Forward/Sunshine Fund Application
The Pay-it-Forward/Sunshine Fund assists Delaware County residents who encounter a sudden event that leaves them with an unexpected and uncovered health-related financial burden. Anyone can submit an application - the individual who experienced a sudden event, a friend, family member, or advocate. Names will be kept confidential, unless the recipient explicitly gives TCF permission to share their information.
Eligibility Requirements. Check all that apply:
*
Applicant/Nominee is a resident of Delaware County, Pennsylvania
Applicant/Nominee has experienced an unexpected event (e.g. car accident, house fire, etc)
Applicant/Nominee has un-covered medical costs (e.g. copays, medications, etc)
Name of Nominee/Applicant
*
First Name
Last Name
Address of Nominee/Applicant
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Contact Person
*
First Name
Last Name
Contact Person's Address (If Different Than Above)
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Contact Person Email
*
example@example.com
Contact Person Phone Number
*
-
Area Code
Phone Number
Best Day/Time to Reach Contact Person
*
Describe the unexpected event or accident that caused hardship
*
How did you hear about this grant?
Word of mouth (friend, family, neighbor)
Social media (Facebook, Instagram)
Web search (Google, Bing, etc.)
Community organization or nonprofit
Healthcare provider or clinic
Other
Describe the unfunded healthcare costs (e.g. co-pays, prescriptions, hospital parking etc)
*
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