Ashley Jonest

Job Title

Applicant Name

Applicant's Birthday

Month

Day

Year

Applicant's Sex:

Male

Female

Multi-line address

Country/Region

Address

City

Zip / Postal code

Person Filing Application

Relationship to Applicant

Phone

Multi-line address

Country/Region

Address

City

Zip / Postal code

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?

Yes

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

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OPTIONAL photo of applicant for website if chosen.

OPTIONAL Applicant Bio for website if chosen (can be different from medical diagnosis above).

Mid-Coast Kid Application

All applicants to be considered as a Mid-Coast Kid must have an application on file. Applications can be filled out online or PDF version of this application can be found here.

PDF Mid-Coast Kid Application