SAILS Referral Form

SAILS Referral Form

This form shall be completed by state of Maryland (MD) residents/partners ONLY.
Date of Referral:

MonthDayYear
Date
Who is providing this referral?
Please explain:
If you answered "other" to Who is providing this referral, please explain.
Individual Needing/Requesting Assistance:

In the section below answer the questions for the invidual who is needing services.
Name:

First NameLast Name
Email:
example@example.com
Phone Number:
Format: (000) 000-0000.
Birth Date:

MonthDayYear
Date
Race:
Please explain:
If you answered "other", please explain.
City:
State:
What type of assistance is needed?:
What type of loss was experienced?
Date of loss
Please explain:
If you answered "other", please explain.
- Mailing Address:
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Sex of Baby:
- Funeral Home's Point of Contact Information
- Name:
  
  First NameLast Name
- Phone Number:
  Please enter a valid phone number.Format: (000) 000-0000.
- Address:
  
  Street Address
  
  Street Address Line 2
  
  CityState
  
  Zip Code
- Upload Invoice(s):
  
  Cancelof
- I verify that this expense and/or contribution is not being covered by another entity. I authorize the funeral home to disclose information regarding the service I requested, my contract and balance to SAILS staff. I also authorize SAILS to contact the funeral home to coordinate payment. I provide consent for SAILS staff to contact me via phone, US mail or email for follow up.
- In the section below answer the questions for the individual who is providing this referral.
- Name of Referring Organization:
- Name:
  
  First NameLast Name
- E-mail:
  example@example.com
- Phone Number:
  Format: (000) 000-0000.
- By typing the word "yes" in the box below, you confirm that you have spoken with the family/person in need regarding this referral.
- How did you first hear about us?
- Please explain:
  If you answered "other", please explain.
- Can we follow up regarding the outcome of this referral?
- Would you like to receive informational and promotional material from SAILS?
Should be Empty: