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Mid-Coast Kid Application

Applicant Name

Applicant's Date of Birth:

Sex:

Male

Female

Applicant Information

Street Address

City

State

Zip Code

Person Filing Application

Name

Relationship to Applicant

Phone

Street Address

City

State

Zip Code

Email Address

Has the applicant received assistance from other organizations, entities, or groups in the past? If yes, please explain:

Does the applicant/family currently have insurance?

Does the applicant/family have an immediate financial need?

How has the diagnosis of the medical condition impacted the life of the applicant/family?

Questions/Comments/Suggestions:

How did you hear about Mid-Coast Smackdown?

Do you know a Mid-Coast Smackdown Board Member? If so, who?

Have you previously applied for assistance from Mid-Coast Smackdown?

Yes

Please include a detailed history of the medical condition, including the grade and/or stage of the condition, approximate time of original diagnosis, treatment to date, and prognosis if known. This application is considered incomplete without a detailed history of medical condition, and will not be considered.

By submitting this application, the person filing the application, and the applicant, agree to be contacted by a representative of the MCSD board for additional follow up. Mid-Coast Smackdown will not release or sell any information obtained in this application.

Name of Person Filing Application

Online Signature-please type name

Date

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