Parent/Guardian Name
*
First Name
Last Name
Parent/Guardian Name
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Contact Name
*
First Name
Last Name
Email
*
Cell Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Home Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Best time to be contacted
Falmouth Resident
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Yes
No
Employed in Falmouth
*
Yes
No
Names and Ages of Children:
Number of Children who are age 18 yrs. or under:
*
List each child below
*
Please explain medical crisis family is experiencing. Include name of patient.
*
What is the time-frame for medical treatment and recovery? (Please provide a letter from the patient’s doctor detailing diagnosis, treatment, length of treatment and location of treatment(s). Letter must be on letterhead and include medical diagnosis form.)
Have you received assistance from the Falmouth Service Center (FSC) such as for food, financial aid or clothing?
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Yes
No
May we contact FSC for a referral?
Yes
No
Do you have health insurance?
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Yes
No
If yes, name of insurance provider:
Who are the employers of the parent(s) / guardian(s)?
*
Is/Are the employer(s) providing paid leave, and for how long? If not, what is the loss of income due to loss of work?
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What are your current financial issues? Please explain how you would utilize our financial assistance if it were to be provided:
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Required Written Documentation
1. Letter or email from the treating doctor (on Doctor’s letterhead) providing diagnosis/treatment and services needed/length of treatment. Please provide a copy of the medical/insurance diagnosis form.
*
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2. A Photo ID of the head of household shall be shown to an Aid Committee member during the interview process.
*
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3. Copy of the family’s rent or mortgage statement.
*
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4. Copies of each minor child's birth certificate
*
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By submitting this application, I/we are confirming that all of the statements above have been answered to the best of my/our knowledge. I/we understand that WFFF is entitled to reimbursement of aid should WFFF find parent(s)/guardian(s) have knowingly provided deceiving and/or false information.(Required)
*
I Agree
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