REQUESTING AID

"Hello! We are so glad that you found us!  Please complete the form below for us to review. We would like to send you our best wishes in your times of need and trouble and hope that our foundation can in some way lend you a helping hand. We look foward to hearing from you!"

The Dawn Stanfill Foundation

Contact information:
Name:	* required
Phone Number:	* required
Email Address:	* required
Mailing Address:
*Child's Date of Birth: * Age of eligibility is up to 18 years old or still in High School.	MONTH January February March April May June July August September October November December DAY 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 YEAR 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009
Medical Information
Name of hospitals you are or have been seen at for pediatric cancer issues and/or treatments:  * required  Doctor's Name(s):  * required  Doctor's Phone Number(s):  * required
Are you willing to release your medical records so we can validate your request? Yes No  Are you willing to meet with us to discuss your situation and how we can help? Yes No
Type of Support:
What type of support are you looking for? Help with medical bills Help with other bills Other Financial Aid Programs and/or fun events we may offer to cheer up your little one Emotional Support (i.e. counseling and/or therapy)
Personal Reference:
Personal Reference Name:  * required  Personal Reference Phone Number:  * required  Personal Reference Email Address:  * required  What is your relationship with this person?  * required
Misc:
Please give a brief description of your situation and any other information you would like for us to know:  How did you hear about us?  * required

****This is a request form that will be reviewed by the board.  All requests will be given equal consideration.  As a foundation we will do our best to assist you however we cannot guarantee to what extent that may be.  We require ample verification of medical records and/or any other bills we may request before any financial aide will be granted.  If you have any other questions you can send us an email and we will get back to you at our earliest convenience.

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