LEND A HAND UP FUNDRAISER REQUEST
PART 2 - FAMILY SIGN OFF
Consent and Information About Medical Challenges
Should be completed by individual or parent/guardian
Please review the fundraiser and boost criteria HERE or find it on the "Start a Fundraiser" page at LendAHandUp.org before proceeding with the Lend A Hand Up Request.
Have the following information available to complete the application. Please forward documentation to the Lend A Hand Up office.
If you'd prefer to print and complete a request on paper, do not use this form; instead use the attached printable PDF request.
To forward documentation or if you have questions about required information and guidelines, please contact the program office: firstname.lastname@example.org or 701-356-2661. Fax: 701-271-0408.
Information about child or adult currently experiencing life-threateningor incapacitating illness or injury, or endured traumatic event leading to loss of life and has (or will) result in substantial out-of-pocket expenses of $5,000 or more.
Section 2B: Medical Information
Section 2C: Out of Pocket Expenses (NOT Covered by Insurance)
Out of pocket expenses include expenses NOT covered by insurance or other programs and include medical bills as well as prescriptions, supplies, mobility devices, home adaptations, gas and lodging (if seeking medical care out of area), and other nutritional/health necessities.
Section 2D: Recipient Signature
REMINDER: Don't forget to mail, email, drop off or fax:
If a Lend A Hand Up representative has not confirmed that your application was received within 3 days of submission, please contact the program office.
Staff:Jeana Peinovich, Lend A Hand Up Director(701) 356-2661, email@example.comHeather Hanson, Lend A Hand Up Coordinator(701) 356-3138, firstname.lastname@example.org
Address:4141 28th Ave S, Fargo, ND 58104