LSF Application for Services

Application for Services
P.O. Box 2168, Scotia, NY 12303 FamilyOutreach@loganstrongfoundation.org www.LoganStrongFoundation.org (518) 930-2384
Childs Name
Preferred Nickname
Date of Birth

MonthDayYear
Date
Age
Date of Diagnosis

MonthDayYear
Date
Parent/Guardian Names
Address

Street Address

Street Address Line 2

City, State, ZipState / Province

Postal / Zip Code
Contact Phone
Format: (000) 000-0000.
Contact Email
example@example.com
Siblings/Ages
Diagnosis
Treatment Stage
Primary Treatment Hospital
Doctor
Referring Agency
Agency Contact
Address

Street Address

Street Address Line 2

City, State, ZipState / Province

Postal / Zip Code
Contact Phone
Format: (000) 000-0000.
Contact Email
example@example.com
Logan Strong Foundation provides the following items and services

Please mark anything you are asking for. You can choose as few or as many of these services we offer.
Online Fundraising Campaign - As a way to assist you to get through the financial hardship of being in the hospital, we help you create a campaign and sell personalized promotional items t-shirts, mugs, stickers, etc to raise money.Wrist Bands - As a way to assist you to get through the financial hardship of being in the hospital, we provide you with 500 wrist bands to sell to raise money and awareness.House Cleaning - We are thrilled to offer $300 worth of interior house cleaning for families house cleaning service of your choiceWish List Items - We ask you to set up a wish list on Amazon.com that is public and share it with us. Our Board of Directors will create a small care package to help you and your little one get through treatments.

Authorized Contacts (may be updated as needed)

Rows	Name	Organization	Phone	Email	Date Auth.

Releases
I authorize the Logan Strong Foundation to use and share the following information for the promotion of services we have received.
Enter name here
1. Photos & Names – I consent to the release of our names and approved photos/images of our family.
2. Medical Information – I consent to the release of my child’s diagnosis, place of treatment, and stage of treatment, as provided and approved by me.
3. Fundraising Assistance – I authorize the Logan Strong Foundation to contact approved individuals or organizations on our behalf to assist with fundraising efforts.
By signing below, I attest that all the information I’ve provided is true and accurate to the best of my knowledge.
Print Name
Relationship
Signature
Date Signed

MonthDayYear
Date
We are honored to support families whenever possible. Please note that all services are subject to review and approval by the Logan Strong Foundation Board of Directors and are based on individual needs, location, and available resources.
Should be Empty:

Application for Services

Releases