Financial Support Request Form

Financial Support Request

We’re here to help you through your rainy days!
If you have, or know someone who has, a seriously ill or injured child in Huron County, please fill out form found below.

These funds can be used to offset any added medical expenses, time off work to be with your child, or special equipment.

If you have any questions about the application process please send us an e-mail.

huntercostellomf@outlook.com
Name*

First NameLast Name
Email*
example@example.com
Cell Phone Number*

Area CodePhone Number
Please select:*

I/We are requesting funds for ourselves / family / child / children; due to a financial hardship caused by illness or injury.I/We know of a family / child / children who are experiencing financial hardship due to illness or injury and with their permission are submitting this application.
Please describe on the nature of your situation. *
Should be Empty: