Evie's Fund Community Care Application

IMPORTANT

Please read before continuing.
Evie's Fund exists because of generous private donations and grant funding. The amount of money available is limited and changes from year to year. Because of this, we will use the information you provide to determine how we can serve you based on our donated milk supply and financial resources. Most families will qualify for just one to two weeks' worth of donor milk at a reduced price.

Click here to learn more about why we charge a processing fee

We may ask for the following documents in addition to your application, but they are not always required:
- Chart notes from a healthcare provider showing the medical need for donor milk and/or a Statement of Medical Need.
- Financial documents, such as paystubs and tax forms, to verify income
Check these boxes to continue:*

I understand that human milk and Evie's Fund are limited resources.I understand I may need to provide additional information to support my infant's need for donor milk.

Evie's Fund Community Care Program

Application for Financial Aid
Please fill out this form with as much detail as you can. The more information you provide, the better we will be able to serve you. You will have an opportunity to share your story at the end of this form.

If you need assistance filling out this form, we would be happy to help you.

Click here to call Northwest Mothers Milk Bank

Parent Profile
Parent Profile
Parent/Guardian Name*

First NameLast Name
Parent/Guardian Pronouns
ex. she/her, he/him, they/them, etc.
Parent/Guardian Date of Birth

MonthDayYear
Date
Relationship to infant(s)*
ex. mom, dad, foster parent, grandparent, etc.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Main Phone Number*
Please enter a valid phone number.
Alternate Phone Number
Please enter a valid phone number.
Email*
example@example.com
Parent/Guardian 2 Name

First NameLast Name
Parent/Guardian 2 Pronouns
ex. she/her, he/him, they/them, etc.
Parent/Guardian 2 Date of Birth

MonthDayYear
Date
Relationship to infant(s)
ex. mom, dad, foster parent, grandparent, etc.
Address (if different from above)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Main Phone Number
Please enter a valid phone number.
Alternate Phone Number
Please enter a valid phone number.
Email
example@example.com
If you or your partner gave birth, is there a current diagnosis that affects the birthing parent's ability to produce milk or otherwise care for the child?

YesNoThe person who gave birth is not involved with the infant's care
If you answered yes, please describe:

ex. receiving cancer treatment, history of breast or chest surgery, hospitalized for sepsis, etc.0/1000

Healthcare Information
Healthcare Provider Contact
Provider Name*
Clinic Name*
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Fax Number
Please enter a valid fax number.
Insurance Provider Contact

NOTE: Some OHP and TriCare plans cover donor milk on an outpatient basis under very specific circumstances.
Do you have Oregon Health Plan or TriCare?

YesNo
If you answered yes, what is the policy number for your infant's plan?

Share Your Story

This helps us understand the unique challenges you are facing.
Please describe recent family events or special circumstances that we should consider while making our decision. Personal appeals describing the need for Community Care are appreciated.

0/1000
Should be Empty:

Evie's Fund Community Care Program