HEADstrong Foundation

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Financial Relief Fund Form

This is not the application for financial aid but a program to help you to raise support with our help. If you are looking for financial aid, please check our website to see if you qualify and fill out the application.

If you are still interested in the relief fund, upon completion of this form, a Patient Care Specialist will follow up within 1-2 businesses days. Our relief fund is currently only open to those located in the Tri-State area of Pennsylvania, Delware and New Jersey. 

If you have any questions, please email support@HEADstrong.org

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Our relief fund is open to those in the tri-state area only.
Contact Information
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First Name
Last Name
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First Name
Last Name
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Address Line 1
Address Line 2
City
State/Province
ZIP/Postal Code
Country
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Address Line 1
Address Line 2
City
State/Province
ZIP/Postal Code
Country
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(mm/dd/yyyy)
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(mm/dd/yyyy)
If you answer "no" to either of the following questions, a Fighter Relief Fund may not be a good option for you:
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First Name
Last Name
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Electronic Certification
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By Clicking, I understand and agree that 90% of the net funds received (less payment processing fees) and adjusted for rejections for insufficient funds returned by the banking institution will be disbursed. HF receives a 10% administrative contribution for the use of their fundraising software, tools, support and incidental fees during the Fundraiser(s).
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The undersigned certifies to HF that he/she meets the eligibility requirements of the Fighter/Relief Program, as described in this Application, and that all the information provide in or with this Application is true and correct.
Our Relief fund is only open to those in PA, DE and NJ. We can offer to send you a comfort kit instead. If you are interested in this, please select this option below and fill out your Name, Address and Diagnosis.
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First Name
Last Name
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Address Line 1
Address Line 2
City
State/Province
ZIP/Postal Code
Country
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