lend a hand application - Dakota Medical Foundation

Transcription

LEND A HAND APPLICATION
Lend A Hand helps you - help others!
LEND A HAND, a program of Dakota Medical Foundation, provides matching funds, online giving
capabilities and other resources to help caring community members raise funds for families living in Cass
County (ND) and Clay County (MN) who are experiencing hardship due to a serious medical condition.
Lend A Hand – Eligibility Guidelines for Matching Funds and Other Resources
Match funding, online giving and other support is awarded to qualifying fundraising efforts based on an application
process. Applications are reviewed monthly by a committee with medical, legal, social service and financial
experience. Funding preference is extended to efforts that invite broad community support by offering many ways
to volunteer and give for the sole purpose of helping a family burdened by substantial expenses due to a
catastrophic medical condition.
Application Deadline: Applications are due the first Wednesday of the month for an event scheduled in a
following month - Ideally, at least 30 days prior to a scheduled event and before flyers are publicly distributed.
Eligibility Checklist – Criteria for Lend A Hand Support
□ A fundraising effort is planned to benefit an individual/family residing in Cass County, ND or Clay County, MN
burdened by life-threatening or incapacitating illness or injury, resulting in substantial expenses. (Lend A Hand
funding is reserved for individuals who have out-of-pocket expenses that exceed $5,000.)
□ The fundraising effort is scheduled 30-60 days in the future, allowing ample opportunity to complete/submit an
application and to build awareness of fundraising activities, online giving options and matching funds.
□ Planned activities offer many ways for people to volunteer and/or make contributions.
□ A reputable nonprofit/charitable organization located in Cass or Clay County is willing to validate the fundraising
effort for the individual/family and offer some type of support such as; volunteers, promotional help, space, food,
auction item(s) or monetary gift. Eligible nonprofits include churches, public schools, fraternal and service clubs.
□ A volunteer committee has been formed, with a designated leader willing to coordinate the submission of an
application to Lend A Hand and to serve as a communication link between volunteers and Lend A Hand.
□ A benefit fund has been established for donation collection and management at a bank/credit union located in
Cass or Clay County, with two or more authorized signers (account managers). Ideally, one of the signers should
be the person experiencing a medical crisis (or a family member), whereas the other signer should be someone
serving on the volunteer committee who does not live with the fundraising recipient.
If Lend A Hand support is approved:
□ Volunteers are agreeable to the inclusion of the Lend A Hand logo(s), website address and notice of matching
funds on event flyers and other items utilized to expand awareness of fundraising activities.
□ The individual recipient and/or guardian is agreeable to fundraising activities and will share information about
contribution amounts with Lend A Hand as necessary to validate match funding amounts.
All 3 sections of the application, along with requested attachments, must be received by the Lend A Hand
program office by the first Wednesday of the month for an event scheduled in a following month.
Applications may be dropped off, mailed, emailed or faxed to:
Lend A Hand, Dakota Medical Foundation, 4141 28 Ave S, Fargo, North Dakota 58104
◊ Fax: (701) 271-0408 ◊ Email: [email protected] ◊ Telephone: (701) 356-2661
Learn more and check out the Lend A Hand Fundraising “How to” Guide: www.dakmed.org/lendahand
LEND A HAND APPLICATION – to apply for matching funds
Page 1 – Information about Fundraising Activities
(to be completed by lead volunteer of the fundraising effort) Please type or print neatly!
400000
dakmed.org/lendahand
Application deadline: the first Wednesday of the month - for a fundraising effort scheduled in a following month
Section 1 – Volunteer Information - lead volunteer must be someone who doesn’t live with the benefit recipient
Lead Volunteer Name:
Street Address:
County Residency: ____ Cass (ND)
____ Clay (MN)
Lead Volunteer Email:
City, State, Zip:
Home Phone:
Cell:
Name of Employer:
Work Phone:
Type and length of affiliation with recipient, such as; friend, coworker, aunt:
Include name and contact information for at least 2 additional people serving on your volunteer committee:
Volunteer Name:
Volunteer Name:
Email:
Email:
Phone:
Phone:
Address:
Address:
City, State, Zip:
City, State, Zip
Affiliation with Recipient:
Affiliation with Recipient:
Section 2 – Benefit Fund Information – validate fund and signers: 1) recipient/family member 2) volunteer committee member
Benefit Fund Name:
Bank/Credit Union:
Bank/Credit Union Address:
County: ____Cass ____ Clay
Fund Started:
City, State, Zip:
Name of Signers:
□ Attach copy of benefit fund signature card verifying fund name, signers and bank information – may cross out personal IDs.
Section 3 – Fundraising Activities - Application should be submitted at least 30 days prior to scheduled activities
Scheduled for (day/date/time):
Event Location (name, address):
Is event open to the public? ___Yes
___No
Place a check by all planned fundraising activities:
___ Mail/Email Campaign ___ Lunch/Dinner Benefit
___ Auction
___ Raffle
___ Music/Entertainment
___ Bake/Craft Sale
___ % of Product Sales
___ Run/Walk/Bike/Bowling/Golf Event
___ Other:
□ Attach a copy of a draft flyer if available. Please save room on the flyer for Lend A Hand logos, online giving site and match
funding information. If approved, Lend A Hand will forward logos and wording to add to flyer.
Section 4 – Lend A Hand Referral Source
How did you learn about DMF Lend A Hand. Check your primary referral source(s):
___ Prior experience
___ Event signage
___ Bank/Credit Union
___ Internet Search
___ Newspaper/Magazine
___ Church/Nonprofit
___ Brochure
___ Television
___ Medical Provider
___ Newsletter
___ Radio
___ Other:
___ Flyer
___Friend/Family
Section 5 – Lead Volunteer Signature
By signing below, I acknowledge that information in this application is accurate to the best of my knowledge. If funding is
approved, I agree to; oversee communication between Lend A Hand staff, the recipient and volunteers, build awareness of
match funding and share documentation of fundraising results. I extend assurance that all proceeds from the fundraising
effort will benefit the named recipient to pay for medical and other related expenses.*
Lead Volunteer Signature:
Date:
*In the unfortunate event of the recipient’s death, Lend A Hand match funding will be honored based on the amount raised
and deposited up until the date of his/her death.
Lend A Hand, Dakota Medical Foundation 4141 28 Ave S, Fargo, North Dakota 58104
◊ Tele: (701) 356-2661 ◊ Fax: (701) 271-0408 ◊ Email: [email protected] ◊ Learn More: www.dakmed.org/lendahand
Page 2 – Information about Medical Challenges and Out-of-Pocket Expenses
(To be completed by individual or guardian who will receive proceeds from fundraising effort). Please Print!
Section 6 – Information about child or adult experiencing life-threatening and/or incapacitating illness or injury
Name of Individual:
Age:
Gender: ___Male ___ Female
This individual is a current resident of ____ Cass County (or) ____ Clay County and has been for ______ year(s)
Home Address:
City, State, Zip:
Email Address:
Employer Name:
Include name(s) and relationship of all individuals living in the same household as this individual. Include ages of children:
Medical Diagnosis/Condition:
Date/timeframe of original diagnosis:
Anticipated length of treatment:
Summarize how treatment/expenses create financial hardship. (May attach separate note.) List expenses in Section 7.
Section 7 – Out-of pocket expenses related to medical care and treatment
Outline expenses related to medical care and rehabilitation of this individual. Only list medical, prescription, equipment and
insurance premium amounts the individual/guardian is liable for (non-covered expenses). Include information about missed
work days, income loss, travel, lodging and other related expenses that increase this financial burden.
Note: Lend A Hand funding is prioritized for individuals/families who have medical and related expenses exceeding $5,000.
Expense Categories
Amount(s) the person/guardian is liable for – AFTER insurance is filed)
*Already Billed and/or /Paid **Estimated Expenses
Past Year & Current Year
For upcoming 12 months
Medical Care (provider, hospital, lab, radiology, therapy charges)
$
Prescriptions/Medications
$
Equipment and Supplies
$
Travel costs to access care: 23.5 cents/mile x
# miles x
# trips = $
Lodging/Food: $125/day per person or $200/day per family x # days = $
Name of out-of-area provider/facility:
Name of Insurance Company/Health Plan:
Amount (if any) you pay for health coverage: $
month x # months = $
Have you applied for Disability/Other assistance? ___Yes ___No
Other major expense(s), note:
$
Total each column
$
$
$
$
$
$
$
$
$
*You may request a report from a clinic, hospital and/or pharmacy showing the total self-paid amount for a given timeframe.
**Future expenses should be estimated based on treatment plans, deductibles, co pays and coinsurance.
Name of person(s) responsible for payment of listed expenses:
If medical care has substantially affected the responsible person(s) income, please specify missed work days or income loss:
Has this individual/family received prior funding from Lend A Hand? ___ No ___ Yes, Date: _______________________
□ Attach copy of driver’s license or other document verifying legal residency, name and age of individual recipient (guardian)
□ Attach copy of medical document (letter, statement, treatment plan) verifying medical diagnosis/condition and provider
□ Attach (optional) *statement verifying total expenses paid and/or billed as non-covered for up to a 2 yr period
Section 8 – Recipient Signature
By signing below, I confirm that expenses listed on this page are accurate and beyond the current financial means of myself
and/or others responsible for payment. I provide assurance that Lend A Hand funding will be used to pay for expenses
related to my medical care and rehabilitation. I give authorization for the use of my photo and information summarizing my
medical crisis for fundraising purposes. I agree to share fundraising results with Lend A Hand to validate match funding.
Recipient Signature:
Date:
If signer is not the individual recipient, print name and relationship:
◊Tele: (701) 356-2661
◊Fax: (701) 271-0408 ◊Email: [email protected] ◊Learn More: www.dakmed.org/lendahand
Page 3 – Nonprofit Support for Benefit/Fundraising Effort
(to be completed by representative of a charitable organization willing to support fundraising effort)
Name of person/family who will receive proceeds from fundraising effort:
Date and location of benefit/event:
Name of Lead Volunteer (benefit coordinator):
Email/Phone:
_____________________________________________________________________________________________________________________________ ____________________________________
Lend A Hand, a program of the Dakota Medical Foundation, provides match funding, online giving and other resources to
qualifying fundraising efforts based on a monthly application process. Funding preference is extended to efforts that invite
broad community support by offering many ways to volunteer and/or give for the sole purpose of helping a family burdened
by substantial expenses due to a catastrophic medical condition.
In order to qualify, the fundraising effort must be supported by a reputable nonprofit organization located in either Cass (ND)
or Clay (MN) County. Qualified nonprofit organizations include churches, schools, public and private charities, as well as
fraternal organizations and service clubs, such as; Lions, Kiwanis, PTA, Boy/Girl Scouts, PEO and Altrusa among others.
Support on behalf of the nonprofit organization may be offered in one or more of the following ways:
 Provide volunteers to plan, promote or serve at the fundraising event
 Donate food, silent auction or other items
 Offer monetary support
 Help promote event: distribute flyers or post announcements in bulletins, newsletters or social media sites
 Donate space for meetings or fundraising activities. Note: organizations/facilities that profit from food, beverage or other
sales as a result of the benefit do not qualify as a validating signer.
The confirmation of support (noted below) does not require the nonprofit organization to serve as a sponsor
and/or coordinator of the fundraising effort.
Section 9 – Nonprofit Organization Information & Confirmation of Fundraising Support
As a representative of a qualifying nonprofit organization, please complete and return this page to the lead volunteer (noted
above) or to the Lend A Hand program office (contact information is noted below).
If you prefer to submit a separate note on letterhead by email, fax or mail, please include the information requested below.
Name of Nonprofit Organization:
Street Address:
City/State:
Zip:
Type/length of affiliation that you and/or the nonprofit organization has with recipient or lead volunteer noted above:
What type of support will your nonprofit organization offer to improve the success of this fundraising effort?
Additional (optional) information/comment:
Section 10 – Signature of Support
Note: The signer must represent a director, principal, clergy member, board president or other person serving in a leadership
role for the nonprofit organization.
By signing below, I confirm that I represent a reputable nonprofit organization willing to actively support a fundraising effort for the individual
named above due to knowledge of their medical hardship.
Nonprofit Director, Principal or Clergy Signature:
Date:
Print Name of Signer:
Title
Telephone Number:
Email:
◊ Tele: (701) 356-2661 ◊ Fax: (701) 271-0408 ◊ Email: [email protected] ◊ Learn More: www.dakmed.org/lendahand

lend a hand application - Dakota Medical Foundation

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