Countryside Scalar Energy Financial Aid Request Form
Please complete this form if you are experiencing serious health challenges and financial hardship. This information helps us review your request for possible support. Submitting this form does not guarantee financial assistance.
Full Name
*
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Preferred Contact Method
*
Phone
Email
Text
What condition, diagnosis, or health challenge are you currently experiencing?
*
Are you currently undergoing or have you recently undergone any of the following?
Chemotherapy
Radiation
Nuclear medicine treatment
None of the above
Are you currently facing a life-threatening illness or deep health challenges?
*
Yes
No
Prefer not to answer
Are you currently experiencing financial difficulty that makes it hard to access care or wellness support?
*
Yes
No
Please briefly describe your current situation and why you are requesting financial aid.
*
Is there anything else you would like us to know about your circumstances?
Acknowledgment
I understand that this form is a request for consideration only and does not guarantee financial assistance.
*
I understand
I certify that the information I provided is true and correct to the best of my knowledge.
*
I certify
By providing my phone number, I consent to being contacted about my inquiry by phone call and/or SMS.
I consent
Submit Financial Aid Request
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