LSF Application for Services

Application for Services
P.O. Box 2168, Scotia, NY 12303 LoganStrongFoundation@gmail.com 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
Contact Email
example@example.com
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
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.
in your local area

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)

	Name	Organization	Phone	Email	Date Auth.

Releases
I authorize the release of our names and photos/images of our family that we have provided or approved, for thepromotion of services we have been provided by the Logan Strong Foundation.
Signature

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I authorize the release of our child’s diagnosis, place of treatment, and stage of treatment information we haveprovided and approved, for the promotion of services provided by the Logan Strong Foundation
Signature

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I authorize the release of our child’s diagnosis, place of treatment, and stage of treatment information we haveprovided and approved, for the promotion of services provided by the Logan Strong Foundation
Signature

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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

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Date Signed

MonthDayYear
Date
Should be Empty:

Application for Services

Releases