Person Filing Application
Relationship to Applicant
Has the applicant received assistance from other organizations, entities, or groups in the past? If Yes, please explain:
Does the applicant/family currently have insurance
Does the applicant/family have an immediate financial need?
How has the diagnosis of the medical condition impacted the life of the applicant/family?
Questions/Comments/Suggestions:
How did you hear about Mid-Coast Smackdown?
Do you know a Mid-Coast Board member? If so, who?
Have you previously applied for assistance from Mid-Coast Smackdown?
Please include a detailed history of the medical condition, approximate time of original diagnosis, treatment to date, and prognosis if known. This application is considered incomplete without a detailed history and will not be considered.
By submitting this application, the person filing the application, and the applicant, agree to be contacted by a representative of the MCSD board for follow up. Mid-Coast Smackdown will not release or sell any information obtained in the application.
Signature Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.
OPTIONAL photo of applicant for website if chosen.
OPTIONAL Applicant Bio for website if chosen (can be different from medical diagnosis above).
