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Financial Relief Fund Form

Upon completion, a Patient Care Specialist will

follow up within 1-2 businesses days.

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

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)
*
*

*

(mm/dd/yyyy)
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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.