New Day Foundation of La Porte Inc Application for Assistance

New Day Foundation of La Porte Inc Application for Assistance
NOTE: All information will be kept strictly confidential except as necessary to
confirm information as set out herein. Submission of application does not ensure
applicants will begranted assistance requested.
Application Date*

MonthDayYear
Date
Applicant's Name*
Age*
Date of Birth*
MaleFemale
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Telephone Number*
Please enter a valid phone number.Format: (000) 000-0000.
ILLNESS
Diagnosis*
Date Diagnosed*

MonthDayYear
Date
General Prognosis*
Treatment Plan*
MEDICAL CONTACTS
Primary Care Physician*
Phone*
Please enter a valid phone number.Format: (000) 000-0000.
Oncologist
Phone
Please enter a valid phone number.Format: (000) 000-0000.
Social Worker
Phone
Please enter a valid phone number.Format: (000) 000-0000.
INSURANCE
If Applicant has Health Insurance, Medicare, or Medicaid please specify*
Number of people currently living in the household?*
Ages of children in the household*
Wages
Applicant*
Household Members*
Social Security
Applicant*
Household Members*
Disability Income
Applicant*
Household Members*
Other (child support)
Applicant
Household Members
Total Income per year
Applicant*
Household Members*
Residence
OWNRENT
Other Assistance for which applicant has applied
1. Health insurance*
2. Medicare/Medicaid*
3. Fuel assistance, SSDI, Food Stamps, VA benefits, NIPSCO energy assistance*
Assistance Requested*
If someone other than the applicant is submitting this application please complete the following:
Name:
Phone:
Email:
Relation to applicant
Name and contact information of a someone NewDayFoundation may contact with questions concerning financial assistance and payment arrangements:
Name:*
Phone:*
Email:*
Relation to applicant*
Other Support
Online SupportEducational Programs/MaterialsReferrals to other resourcesTransportation
General Release
I/We wish to participate in the benefits provided by the NewDay Foundation of La Porte, Inc.
I/We understand that our participation in such a program is wholly voluntary and that these benefits
are provided by "NewDay Foundation" in furtherance of its humanitarian endeavor to provide
financial support to La Porte area residents who are battling cancer without the assistance of health
insurance and/or who are in financial difficulties or in need of other assistance. I/We understand
that we have not been given any assurance of benefits/assistance.
1/We hereby assume all risks and responsibility for any damages or injury (including the aggravation
of any existing illness or condition), which we or our family may sustain as a result of our
participation in the benefits provided by the "NewDay Foundation," its officers, directors, agents,
sponsors, medical advisors, volunteers, and employees.
I/We hereby release, discharge, indemnify and agree to hold harmless "NewDay Foundation," its
officers, directors, agents, sponsors, medical advisors, volunteers, and employees from all claims,
demands, causes of action, present or future, whether known, anticipated or unanticipated, resulting
from arising out of, or incidental to our participation in the programs or benefits provided by
"NewDay Foundation.
In Witness thereof this day* day of month , Year year
Signed:*

Clear
Witness:*

Clear
Authorization for Release of Medical or Hospital RecordsAnd/or Disclosure of Medical Information
I am requesting financial assistance from the NewDay Foundation of La Porte, Inc. in
obtaining medication, supplies, help with living expenses or Medical costs. To that
extent, I hereby authorize my Doctors and/or Hospitals to provide any needed
information the NewDay Foundation of La Porte may need to assist in determining
my eligibility to receive such financial assistance.
I understand that NewDay Foundation will utilize the information received in order
to assist in evaluating my need and providing assistance, and that this use may
include maintenance of this information as a part of NewDay Foundations internal
records, or disclosure to other charitable organizations (including but not limited to
the Unity Foundation) in an effort to assist me in obtaining aid. I hold NewDay
Foundation harmless as to any inadvertent disclosure of information done in good
faith.
Signature*

Clear
Date*

MonthDayYear
Date
Name*
Should be Empty:

New Day Foundation of La Porte Inc Application for Assistance

ILLNESS

MEDICAL CONTACTS

INSURANCE

Wages

Social Security

Disability Income

Other (child support)

Total Income per year

Residence

Other Assistance for which applicant has applied

If someone other than the applicant is submitting this application please complete the following:

Name and contact information of a someone NewDayFoundation may contact with questions concerning financial assistance and payment arrangements:

Other Support

General Release

Authorization for Release of Medical or Hospital RecordsAnd/or Disclosure of Medical Information