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

Email *

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 the following states: PA, NJ, DE, MA, NY, CT, VT, NH, RI, ME. 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/ Please also check out our website at the link below for other resources https://bit.ly/4d4S221