Monthly Assistance Request must be applied for by a medical social worker or health care provider.

We understand the financial strain a childhood cancer diagnosis brings. Monthly assistance is awarded to help a family for consecutive months when they are experiencing extreme financial difficulties due to parents need to take a leave of absence from work to care for their critically ill child. Aid will come in the form of gas, grocery or partial rent assistance and will be based on need and availability of funds. Sufficient documentation of need is required. Guidelines are used to qualify families for this monthly aid. Limitations and restrictions will be used to ensure assistance is not abused.

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* 1. Type of Monthly Assistance Requesting?

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* 2. Provide brief explanation of patient situation and financial hardship:

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* 3. Explain why your family needs extended assistance for 3 months:

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* 4. Has one or both parents missed work due to child's illness?

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* 5. Please indicate total monthly income loss due to missed work caring for sick child?

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* 6. If parent/s are on a leave of absence from work, how long will they be off?

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* 7. Patient Information:

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* 8. Estimated Monthly Family Income and Assets:

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* 9. Estimated Monthly Immediate Family Expenses:

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* 10. Patient's Medical Information: (Should Be Completed By The Patient's Doctor, Nurse, or Medical Social Worker):

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* 11. Include any additional comments below. Megan's Wings will review all information provided & reply to person submitting request within 2-3 days. Funds are limited and based on availability. All information provided is kept confidential and used only to help Megan's Wings determine need. Please email any support documents to ksavage@meganswings.org or fax to (909) 942-6808 and indicate Child's Name on paperwork.

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