| I am making an application for: |
| Children's Name: |
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| Age |
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| Parent 1 Name: |
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| Parent 2 Name: |
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| Phone Number |
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| Email Address |
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| Address: |
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| City: |
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| State: |
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| Zip Code: |
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| Parent 1 Employee: |
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| Parent 2 Employee: |
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| Parent 1 Work Number: |
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| Parent 2 Work Number: |
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| Number of Children: |
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| Ages: |
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Medical Information |
| Type of Illness: |
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| When diagnosed: |
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| Other Treatment facilities involved in child's care: |
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| Describe briefly the treatment Program: |
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| Where is the treatment being administered and by what Physician: |
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Insurance Information: |
Is the patient covered by private insurance:
Yes
No |
Is the patient covered by a state funded plan:
Yes
No
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| If so what plan: |
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| What is the deductible: |
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| Percentage of coverage: |
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Prescriptions Expenses |
| Prescription needed: |
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| Cost of Prescription: |
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Has money been raised on behalf of the applicant? |
Yes
No |
| If so how much? |
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| If you have applied for or received assistance from another organization please list below: |
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| With what specific needs can the Jadyn Fred Fund assist you or your family? |
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| Who did you obtain this web site from? |
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| Application submitted by: |
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| Address: |
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| Phone Number: |
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Please fax Doctors reports to:
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