DMF Lend A Hand Application - Lend A Hand Program.doc

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					                                                DMF Lend A Hand Application
                               To apply for matching funds, online giving options, and other resources

Lend A Hand offers resources to help volunteers raise funds for families experiencing financial hardship
due to a medical crisis. DMF match funding and online giving options are limited to efforts that help legal
residents of Cass County, ND or Clay County, MN with $5,000 or more of out-of-pocket medical expenses.
If you are planning a fundraising effort and would like to apply for DMF Lend A Hand matching funds:
1. Form a volunteer committee with a designated lead volunteer in Cass/Clay County willing to oversee meetings and
    communication. The lead volunteer should not be a member of the recipient’s immediate family/household.
2. Establish a benefit fund at a local bank/credit union with at least two account signers, one representing the
    volunteer committee, and one representing the recipient/family depending on bank/credit union policies and if/how
    account assets may affect other benefits. Learn more: www.dakmed.org/lendahand, Fundraising Toolkit, Step 2.
3. Complete this application form with information about the medical crisis and planned fundraising activities.
4. Obtain input and signatures for: 1) lead volunteer, 2) fund recipient and 3) nonprofit director, principal, or clergy in
    Cass/Clay County to validate knowledge of recipient’s medical situation and offer fundraising support. The recipient
    must approve the use of their picture and information summarizing their medical condition for fundraising purposes.
5. Submit request by the 15th of the month for activities scheduled in a following month(s). For example; 1-2 months
    prior scheduled event and/or before marketing efforts are underway/flyers distributed. Past efforts are not eligible.

Section 1        Volunteer Information (lead volunteer should not be a member of recipient’s immediate family/household)
Lead Volunteer Name: ____________________________________ Email: _________________________________
Street Address: ______________________________________ City/State/Zip: _________________________________
County: Cass ____ or Clay ____ Home Tele #: _______________ Work/Cell: _________________/_______________
Do you represent a business/organization sponsoring the effort? ___ No ___Yes/Name: _________________________
How do you know the recipient? ______________________________________________________________________
Include name and contact information for at least 2 additional volunteers (may attach separate page with additional names):
Volunteer Name: ________________________________ Volunteer Name: ____________________________________
Relationship to Recipient:__________________________ Relationship to Recipient: _____________________________
Email or Phone: _________________________________ Email or Phone: _____________________________________
Address: _______________________________________ Address: __________________________________________
City/State/Zip: __________________________________ City/State/Zip: ______________________________________

Section 2        Benefit Fund Information (one of the volunteers listed above should serve as a benefit fund account signer)
Benefit Fund Name: ________________________________ Bank/Credit Union: ___________________________
Bank/Credit Union Address: ____________________________ City/State/Zip: _________________________________
County: Cass ___ or Clay ____ Fund Started: ___________ Account Signers: __________________________________
►Attach copy of signature card or other document verifying existence of fund, authorized signers, and bank location.

Section 3        Fundraising Activities (application should be submitted 1-2 months before scheduled event/activities)
Place a check by any/all planned fundraising activities. Include detail (as known) regarding date, time,
location, and other relevant information. If flyer and/or appeal letter is already drafted, please attach.
____   Community/Public event              ____ Mail/email campaign     ____ Sale of individual baked goods, crafts, clothing
____   Company/association event           ____ Lunch/Dinner benefit    ____ Business to donate % of food/product sales
____   Church/faith-based event            ____ Auction and/or raffle   ____ Run/walk/bike/golf/bowling/athletic event
____   Neighborhood/family/friends event   ____ Entertainment/Music     ____Other: ___________________________________
Date/Time(s): _____________/_____________ Location: _______________________________________________
Additional information about fundraising activities, major sponsors, and the type/amount of support already secured:
_________________________________________________________________________________________________


Section 4        DMF Lend A Hand - Referral Source & Prior Assistance
How did you learn about DMF Lend A Hand? Check your primary referral source(s):
____   Prior Experience with Program             ____ Fundraising Event         ____ Internet Search
____   Printed Materials: ____ Ad ____ Flyer ____Brochure ____ Newspaper/Magazine ____ Newsletter    ____ Other
____   Word-of-Mouth: ____Friend/Family      ____Bank      ____Medical Provider ____Church/Nonprofit ____Other
____   Broadcast Ad/Story: ____TV ____Radio      ____ Other Source: _____________________________________________
Please include name and/or location of referral source (optional):______________________________________
Section 5       Fund Recipient - Medical Crisis Information
A. Please provide information regarding the individual(s) experiencing a medical crisis (fundraising recipient/family).
Recipient Name: ____________________________________________ Age: ___________ Gender: ____________
Recipient is a current legal resident of _____ Cass County, ND or _____ Clay County, MN for______ year(s)
Home Address: __________________________ City/State/Zip: ________________________ Tele #: ______________
Email Address: _____________________________ Employer: ______________________________________________
Include name(s) and relationship of all members of the immediate household. Include ages of children:
_________________________________________________________________________________________________
B. Medical Diagnosis/Condition: ___________________________________________________________________
Summary of Medical Crisis. Summarize how the medical condition, medical care and non-covered expenses have
created financial hardship for the recipient/family. (May attach separate page.)
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
C. Provide information regarding type and amount of out-of-pocket (non-covered) medical expenses
List out-of-pocket medical expenses as accurately as possible based on medical bills already received, as well as anticipated expenses
for up to a one year time period. Estimate future expenses based on health coverage (or lack of) including deductibles and co-pays
(per number of visits/hospital stays), co-insurance, travel/lodging costs, and non-covered treatment, medication and supplies.

Medical Expense Categories                                                   Out of Pocket Expenses for Recipient/Family
                                                                                           Already Billed/Paid     Future/Estimated
                                                                                           (current/past year)   (for next 12 months)
Category 1 – Medical Care
A. Clinic, hospital, outpatient and home care charges including provider charges, testing
   and treatment (lab, x-ray, dialysis, radiation, chemotherapy, PT/OT, and IV therapy) $_______________         $_______________
B. Prescription medications/pharmacy                                                       $_______________      $_______________
C. Other: ______________________________________________________________                   $_______________      $_______________
Category 2 – Equipment & Supplies
A. Wheelchair, walking aides, assistive equipment for bath/toilet, hospital bed, vehicle
   handicap retrofitting, other:______________________________________________             $_______________      $_______________
Category 3 – Dislocation Costs
Reason for travel to out-of-area provider: _____________________________________
Name of medical facility:________________________________ City:_______________
A. Travel Expenses at .50/per mile: # Miles roundtrip: ___________ # Trips: ________        $_______________ $_______________
B. Lodging/Food at $125/day per person, $200/day family: # Overnight stays: ________ $_______________ $_______________
C. Other: ________________________________________________________________ $_______________ $_______________

Category 4 – Health Coverage (Insurance Premium/Recipient Liability)
A. Name of insurance carrier/coverage program: _________________________________
   Recipient/family is liable for: $___________ x _______ months to maintain coverage      $______________       $_______________
B. If no coverage, has the individual/family applied for Medicaid/other help? ___No ___Yes
   Optional comment: _______________________________________________________

Category 5 – Other
A. Description: _____________________________________________________________ $______________ $_______________
Total for Two Columns (Already/Billed Paid and Estimated Expenses):                          $______________ $_______________
TOTAL OUT OF POCKET MEDICAL EXPENSES FOR THE RECIPIENT/FAMILY:                               $ _______________________________

D. How will contributions be used by the individual/family fundraising recipient?
_________________________________________________________________________________________________
_________________________________________________________________________________________________
E. Has the individual recipient/family received prior help from DMF Lend A Hand?
___No ___Yes, Amount $__________ Date: __________ Recipient/Fund Name: _______________________________
3 signatures of verification must be obtained as designated below.
Section 6        Signatures of Verification                   Benefit Fund Name: ____________________________
A. Lead Volunteer – Verification/Signature
By signing below, I acknowledge that information provided on this document is complete and accurate to the best of my knowledge.
By submitting this application, I understand that DMF Lend A Hand will review the disclosed information. I understand that match
funding and other forms of supportive services are not guaranteed and that DMF Lend A Hand will notify me of the status of this
request within 30 days following its receipt. If approved, I will work cooperatively with Lend A Hand guidelines to assure all proceeds
benefit the recipient.

► Lead Volunteer Signature: _______________________________ Date: ____________ Print Name: ___________________________

B. Recipient – Verification/Signature
By signing below, I confirm that the non-covered expenses listed on this document are accurate and create financial hardship for
me/family members who maintain responsibility for payment of these expenses. I certify that any DMF Lend A Hand funding
received shall be used for the sole purpose(s) designated on this document. I give authorization for the use of my photograph and
information summarizing the medical crisis for fundraising purposes. (No financial data is shared in a public format.)

►Recipient Signature: _____________________________________ Date: ____________ Print Name: ____________________________
If signature above is that of spouse, parent, or other legal guardian, note relationship to recipient: _________________________________________

►Attach copy of driver’s license or other identification verifying name, residency and age of recipient.

C. Nonprofit/Church Organization – Verification/Signature
Obtain input and signature of a nonprofit director, principal, or clergy member representing a religious, fraternal, civic, community,
medical, public school, or other nonprofit organization in Cass or Clay County willing to validate knowledge of medical hardship for
this individual/family or an affiliation with the lead volunteer of the effort. Validation does not signify management of funds/activities.

Name of Church/Nonprofit Organization: _____________________________________________ County: ________________
Street Address: ___________________________________ City/State: __________________________ Zip: ___________________
Note the type and length of affiliation that you/your nonprofit organization has with the lead volunteer and/or the recipient/family:
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
What type of support will the non-profit offer to improve the success of this fundraising effort? (For example; do you plan to post a
bulletin announcement, distribute flyers, or provide space, volunteers, food, items, and/or monetary assistance?)
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Additional (optional) information regarding affiliation noted above and/or this request for Lend A Hand resources/match funding:
________________________________________________________________________________________
By signing below, I validate/acknowledge support for this fundraising effort on behalf of the nonprofit/church I represent.

►Nonprofit Director, Principal, or Clergy Signature: _______________________________________________ Date: ___________________
Print Name and Title of Signer: _________________________________________________/______________________________________________

                  Please submit application as soon as possible to maximize DMF Lend A Hand resources!
  Forward completed form with required signatures, a copy of recipient’s driver’s license (or other document verifying
his/her identification and address) and a copy of the benefit fund signature card by the 15th and 30 days prior event to:
                                     Dakota Medical Foundation/Lend A Hand
                                              4152 30 Ave S, Suite 102
                                             Fargo, North Dakota 58104
◊Fax: (701) 271-0408 ◊Email: jeanapeinovich@dakmed.org ◊Program Office Telephone: (701) 356-2661
Lend A Hand committee members meet monthly to review applications received by the 15th day of the current month for events
scheduled in future month(s). Applications received after the 15th will be submitted for review in the following month.
     Additional resources are available on the DMF Lend A Hand website: www.dakmed.org/lendahand
For DMF Lend A Hand use only

____ Approved for matching funds: $ _______________ Date notified: ___________ Volunteer Meeting: ____________________
     Online Giving Site set up: ____________ Flyer Approved/Printed: ___________ Mktg. Items shared: ___________________
     Survey Sent/Returned: __________ /_________ Check presented: ___________ Other: ______________________________
____ Denied, Reason: ________________________________________________________ Notification Date: _________________
     Referral/Follow-up: _______________________________________________________________________________________
Signature: ___________________________________________ Title: _______________________________ Date: _________________
                                                                                                                               Revised 12/05/10

				
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