Compassion Care Family Assistance Program

Compassion Care Family Assistance Program

We understand and respect that the person completing this request may not be an immediate family member. It is imperative however, that you authorized family representative and have received permission to provide any information included in this form.
After submitting this form, a member of our team will review your request and contact you within 3–5 business days. All information is kept confidential. Submission does not guarantee funding, but every request is prayerfully and thoughtfully considered.
Contact Information

Please provide the information for the person we will be communicating with most frequently.
Name

First NameLast Name
Relationship to child?
Email
example@example.com
Phone Number
Please enter a valid phone number.
Preferred method of contact
Child's Information

Please provide the information of the child that was involved in tragedy.
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Please provide details regarding family's tragedy.
What support services are you and/or the family seeking? (check all that apply)

Bereavement Materials/ResourcesFinancial SupportGrief Support NetworkOther
Primary Financial Need (Optional)

Funeral/Memorial ExpensesTravel/LodgingMedical BillsCounseling/TherapyHousehold EssentialsOther
Preferred Method of Assistance

Check mailed to addressElectronic Payment (Zelle/Venmo/Other)Direct Payment to Service ProviderOther
Payee Name (if different)
Confidentiality Notice

All information provided will be used solely for the purpose of evaluating and administering assistance and will not be shared outside Naomi’s Grace without permission, except as required by law.
Acknowledgement & Consent

By signing below, I am acknowledging that I am either the patient or the patient's personal representative OR I have received written consent from the patient or patient's personal representative to complete this request on their behalf. I further understand that all information provided in this form is true and correct, to the best of my knowledge.
Signature

Clear
Printed Name
How did you hear about this program?
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Compassion Care Family Assistance Program

Contact Information

Child's Information

Confidentiality Notice

Acknowledgement & Consent