Hardship Assistance Application

Hardship Assistance Application
At this time, Fight CF Foundation hardship grants are available to cystic fibrosis patients who receive care at Children's Hospital of The King's Daughters in Norfolk, VA or Naval Medical Center in Portsmouth, VA.
Cystic Fibrosis Patient Name*

First NameLast Name
Patient Date of Birth*

MonthDayYear
Date
Which best describes you in relation to the CF patient?*

Self/CF PatientParentGrandparentLegal GuardianOther
Primary Caretaker Name*

First NameLast Name
Mobile Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email*
example@example.com
Patient's Primary Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Tell us about your CF Care Center
Care Center Name*
City, State*
Coordinator/Social Worker *
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Fight CF Foundation requires verification of the patient's CF diagnosis from your CF Care Center. Please obtain a letter from your CF Care Center with the patient's name, date of birth, and verification of thier diagnosis.

Verification letter can be emailed to grants@fightcf.com or text to (757) 705-0014
Tell us about your situation
Which situation best describes your need for assistance?*

Food InsecurityHousing (Mortgage/Rent)UtilitiesEducationOther
Please provide a brief summary explaining your present need (minimum 25 words required)*

0/0
How were you referred to us?*

Social WorkerDoctorFamily/FriendCompassOther
Has anyone else applied for this grant on behalf of this CF patient?*

YesNo
Is the CF patient related to a Fight CF Foundation board or staff member?*

YesNo
Fight CF Foundation hardship grants are limited to one $500 grant per 12 month period for each cystic fibrosis patient based on application approval and available funding.

Fight CF Foundation hardship grants are only available to cystic fibrosis patients who receive care at Children's Hospital of The King's Daughters in Norfolk, VA or Naval Medical Center in Portsmouth, VA.

I hereby certify that, to the best of my knowledge, the information provided is true and accurate.
Signature*
Should be Empty:

Hardship Assistance Application

Tell us about your CF Care Center

Tell us about your situation