Financial Relief Fund Form

Please review carefully the detailed information located on our website about the Relief Fund. This is not the application for financial aid but a program to help you to raise support with our help.

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 open to only those in the following states: PA, NJ, DE, MA, NY, CT, VT, NH, RI, ME

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

Contact Information

Name

First Name

Last Name

Are you the Patient receiving treatment?

Yes

Patient's Name

First Name

Last Name

Verify Email

Permanent Address

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

Country

Is patient's address the same as yours?

Yes

Patient's Address

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

Country

Primary Phone

Secondary Phone

Date of Birth

(mm/dd/yyyy)

Gender

Male

Female

Non-Specific

Diagnosis

Date of Diagnosis

(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:

Do you have a supportive community that would back a community effort on your behalf?

Yes

Do you have a delegate (Family Member, Neighbor, Friend) that would be interested in taking this off your plate and being the point person?

Yes

Name of Family Member or Friend

First Name

Last Name

Please explain how this program from the HEADstrong Foundation will assist with financial hardship caused by your medical condition

Electronic Certification

The undersigned agrees to the below

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).

I Agree

The undersigned certifies the below

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.

I agree

Unfortunately, you do not qualify for a Relief fund

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 visit this link for more information and the form to fill out. https://headstrong.org/comfort-kits/

Comfort Kit