Evie's Fund Community Care Application

Evie's Fund Community Care Application

Application for Financial Aid for Families with Critically Ill Infants
PLEASE NOTE: This application is for families with infants who have a critical medical need. Description of critical need can be found on our website here. If your baby does not have a diagnosis defined by the critical need categories please do not submit this application. NWMMB has a limited amount of Rapid Relief funding which may be available based on availability and diagnosis. More information can be found here.

You may also reach out to us directly at 1-800-204-4444.
Do you have a prescription for donor milk?
All families must have a valid prescription before we can provide donor milk, regardless of whether they are part of the Community Care Program. Please call your infant's doctor and ask them to fax a prescription to us. Our fax number is 503-469-0962. A link to our order form can be found on our website here.

Please review our Notice of Privacy Practices here.

We can't consider your application for financial aid until we have a prescription. Please give us a call at 503-469-0955 (toll free 1-800-204-4444) and we'll be happy to answer your questions about this process!

Click to call Northwest Mothers Milk Bank

Click to return to DonateMilk.org

IMPORTANT

Please read before continuing.
Evie's Fund exists because of generous private donations and grant funding. The amount of money available is limited and changes from year to year. Because of this, we will use the information you provide to determine how we can serve you based on our donated milk supply and financial resources. Most families will qualify for just one to two weeks' worth of donor milk at a reduced price.

Click here to learn more about why we charge a processing fee

We may ask for the following documents in addition to your application, but they are not always required:
- Chart notes from a healthcare provider showing the medical need for donor milk and/or a Statement of Medical Need.
- Financial documents, such as paystubs and tax forms, to verify income
Check these boxes to continue:

Evie's Fund Community Care Program

Application for Financial Aid
Please fill out this form with as much detail as you can. The more information you provide, the better we will be able to serve you. You will have an opportunity to share your story at the end of this form.

If you need assistance filling out this form, we would be happy to help you.

Click here to call Northwest Mothers Milk Bank
- Infant Profile
  
  You may add twins or triplets at the end of this section. This form only has space for three infants. If you are caring for more than three infants at once (ex. quadruplets) please let milk bank staff know.
- Infant Name
  
  First NameLast Name
- Infant Date of Birth
  
  MonthDayYear
  Date
- Infant Sex
- Please select the circumstance that best describes your infant(s):
  
  Other
- If other, please describe:
- Infant's weight at birth
  ex. 6 pounds, 10 ounces
- Infant's current weight
  ex. 10 pounds, 6 ounces
- Was your infant term (born on time) or preterm (born early, before 37 weeks)?
- What was your infant's gestational age at birth?
  ex. 40 weeks
- Is your infant currently in the hospital?
- Which hospital?
- What is your infant's diagnosis?
  
  ex. failure to thrive, tongue tie, preterm, etc.0/1000
- Was your infant part of a multiple birth?
- Infant 2 Profile
- Infant 2 Name
  
  First NameLast Name
- Infant 2 Date of Birth
  
  MonthDayYear
  Date
- Infant 2 Sex
- Please select the circumstance that best describes your infant(s):
  
  Other
- If other, please describe:
- Infant 2's weight at birth
  ex. 6 pounds, 10 ounces
- Infant 2's current weight
  ex. 10 pounds, 6 ounces
- Was infant 2 term (born on time) or preterm (born early)?
- What was infant 2's gestational age at birth?
  ex. 40 weeks
- Is infant 2 currently in the hospital?
- Which hospital?
- What is infant 2's diagnosis?
  ex. failure to thrive, tongue tie, preterm, etc.
- Infant 3 Profile
- Infant 3 Name
  
  First NameLast Name
- Infant 3 Date of Birth
  
  MonthDayYear
  Date
- Infant 3 Sex
- Please select the circumstance that best describes your infant(s):
  
  Other
- If other, please describe:
- Infant 3's weight at birth
  ex. 6 pounds, 10 ounces
- Infant 3's current weight
  ex. 10 pounds, 6 ounces
- Was infant 3 term (born on time) or preterm (born early)?
- What was infant 3's gestational age at birth?
  ex. 40 weeks
- Is infant 3 currently in the hospital?
- Which hospital?
- What is infant 3's diagnosis?
  ex. failure to thrive, tongue tie, preterm, etc.
- Parent Profile
- Parent/Guardian Name
  
  First NameLast Name
- Parent/Guardian Pronouns
  ex. she/her, he/him, they/them, etc.
- Parent/Guardian Date of Birth
  
  MonthDayYear
  Date
- Relationship to infant(s)
  ex. mom, dad, foster parent, grandparent, etc.
- Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Main Phone Number
  Please enter a valid phone number.Format: (000) 000-0000.
- Alternate Phone Number
  Please enter a valid phone number.Format: (000) 000-0000.
- Email
  example@example.com
- Parent/Guardian 2 Name
  
  First NameLast Name
- Parent/Guardian 2 Pronouns
  ex. she/her, he/him, they/them, etc.
- Parent/Guardian 2 Date of Birth
  
  MonthDayYear
  Date
- Relationship to infant(s)
  ex. mom, dad, foster parent, grandparent, etc.
- Address (if different from above)
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Main Phone Number
  Please enter a valid phone number.Format: (000) 000-0000.
- Alternate Phone Number
  Please enter a valid phone number.Format: (000) 000-0000.
- Email
  example@example.com
- If you or your partner gave birth, is there a current diagnosis that affects the birthing parent's ability to produce milk or otherwise care for the child?
- If you answered yes, please describe:
  
  ex. receiving cancer treatment, history of breast or chest surgery, hospitalized for sepsis, etc.0/1000
- Employment and Financial Information
- Parent/Guardian 1 Occupation
- Parent/Guardian 1 Employer
- Are you currently working?
- Parent/Guardian 2 Occupation
- Parent/Guardian 2 Employer
- Is parent/guardian 2 currently working?
- Select the situation that best describes your household:
- Annual Household Income
- How many people live in your household?
- Please list the children or dependents in your care, as well as their ages:
  ex. Riley, 4; Dorothy, 85
- Please list any government assistance programs you or your dependents are already eligible for:
  ex. SNAP, WIC, free or reduced school lunch, etc.
- Healthcare Provider Contact
- Provider Name
- Clinic Name
- Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Phone Number
  Please enter a valid phone number.Format: (000) 000-0000.
- Fax Number
  Please enter a valid fax number.Format: (000) 000-0000.
- Insurance Provider Contact
  
  NOTE: Some OHP and TriCare plans cover donor milk on an outpatient basis under very specific circumstances.
- Do you have Oregon Health Plan or TriCare?
- If you answered yes, what is the policy number for your infant's plan?
- Demographic Information
- Race of infant(s):
  
  Other
- Ethnicity of infant(s):
- Feel free to add more detail or clarification:
- Please select the statement(s) that best describes your parenting arrangement:
  
  Other
- You can tell us a little more about your parenting situation here:
  
  0/1000

Share Your Story

This helps us understand the unique challenges you are facing.
Please describe recent family events or special circumstances that we should consider while making our decision. Personal appeals describing the need for Community Care are appreciated.

0/1000
Should be Empty:

Evie's Fund Community Care Application

IMPORTANT

Evie's Fund Community Care Program

Infant Profile

Infant 2 Profile

Infant 3 Profile

Parent Profile

Employment and Financial Information

Healthcare Provider Contact

Insurance Provider Contact

Demographic Information

Share Your Story