Applicant Name
*
Person completing this form.
First Name
Last Name
Relationship to Recipient
Applicant Email Address
*
Applicant Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Applicant Phone
(###)
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Recipient Name
First Name
Last Name
Recipient or Family Email
Recipient Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Recipient Phone
(###)
###
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Explanation of Request
Please provide an explanation of the community fundraiser being planned including, the title of the fundraiser, the date, the time and the place of the fundraiser. In addition, please provide a budget detailing the anticipated donations to be received and expenses that will be incurred in conducting the community fundraiser for which you will seek reimbursement, e.g. venue rental, event insurance or catering.
Please provide a detailed explanation of the reason that the fundraiser is being held.
Please include the patient’s diagnosis, date of birth and date of diagnosis. In addition, please provide a detailed explanation of the purpose for which the community fundraiser is being held e.g. purchase of handicapped equipped van, home modifications for handicapped accessibility, uninsured medical and related expenses.
Please describe how the family's financial situation has changed since the diagnosis.
Lost income, unreimbursed medical expenses, extensive hospital stays, etc.
Please provide any other information relevant to this application.
How did you hear about Neighbors Fundraising For Neighbors?
Please note, the policy of Neighbors Fundraising For Neighbors is as follows: 1. All requests for the disbursement of monies raised by the community fundraiser will be made only upon the submission of an invoice from the supplier/vendor of the service for which the fundraiser was held. All invoices must include the name and address of the supplier/vendor as well as a Social Security or Employee Identification Number (EIN). 2. Payments will be made only to these suppliers/vendors. However, the Board reserves the right to make exceptions to this policy and in certain circumstances will make payments to the beneficiary of the community fundraiser. 3. If the “purpose” of the fundraiser is modified after the Board considers and approves this application then a revised application must be submitted and approved before any disbursement of monies raised will occur. 4. If a recipient raises more monies then are needed to satisfy the purpose of the community fundraiser, the excess monies will be held by Neighbors Fundraising For Neighbors for the future benefit of the recipient. By clicking on "Submit Application", you are acknowledging the above policies and agree with them.