Emergency Assistance Request Form 2026

Emergency Assistance Request Form

2025 - 2026
Submitting this request does not guarantee payment. Approval is at the discretion of the Arizona Bleeding Disorders (Member Services Department) and is contingent on availability of funds for this program. Once the application has been submitted, please allow 1-2 weeks for processing. Assistance is limited to a maximum of $500 per 12 months with a minimum of 3 months between requests, per household. In the presence of special circumstances, the AZBD Executive Director will review exceptional requests.
Please review the guidelines thoroughly.
Eligibility Guidelines:
- Applicant must be a resident of Arizona and an active Member of Arizona Bleeding Disorders.
- AZBD reserves the right to take into consideration whether an applicant has been a “no show” at an event.
- Applicant must have a diagnosed bleeding disorder or be the parent or guardian of a minor child who lives in the same household who has been diagnosed with a bleeding disorder.
- A copy of the outstanding bill or invoice is required and must be included with this application.
- Applicants must complete all sections of the application thoroughly and accurately and provide corresponding documentation if requested.
- Assistance is available for rent, mortgage, and utilities. Anything other than the previously mentioned must be approved by the Executive Director.
Section 1: Individual Requesting Assistance - Contact Information
Full Name:*

First NameLast Name
Birth Date*

MonthDayYear
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Section 2: Bleeding Disorder Member Information
Name of Person Diagnosed with Bleeding Disorder.
Section 3: Other Household Members
List Other Household Members (Not Diagnosed).
Section 4: Invoice Bill Information

*All approved assistance payments are sent directly to the vendor.*
Name of Payee:*
Company/Vendor Name
Account #
If applicable
Requested Amount: *
Bill Due Date*

MonthDayYear
RentMortgageUtility (Water, Gas, Cellular Service)Medical ExpenseOther
Address of Payee*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Please include a copy of the bill referenced in request and any other information necessary to support your request. *

Cancelof
Additional Comments/Notes
Section 5: Other Assistance Requested

AZBD assistance should be considered a last option. Please list 3 other organizations or resources you contacted for assistance prior to the association.
1. Organization Name*
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
2. Organization Name*
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
3. Organization Name*
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Section 6: Hardship Explaination
Briefly describe the circumstances that led to this financial hardship.*
Describe how your bleeding disorder contributed to this hardship. *
Section 7: Acknowledgement
I certify that the information I have provided in this application is true and correct. I consent to the release of this information in this application to the Arizona Bleeding Disorders or other social service agencies, groups, HTC's, utility companies, etc which may assist and contribute to receiving emergency assistance funds.
Print Name*
Signature*

Clear
Date*

MonthDayYear
Should be Empty:

Emergency Assistance Request Form

Please review the guidelines thoroughly.