AID APPLICATION FORM

Parent/Guardian Name:
Parent/Guardian Name:

Street/PO Box:
Town:
Zip Code:

Contact Name:
Email:
Home Phone:
Cell Phone:
Best time to be contacted?

Falmouth Resident? YesNo
Employed in Falmouth? YesNo

Number of Children who are age 18 yrs. or under: 123456

Names and Ages of Children:

Please explain medical crisis or tragedy family is experiencing. If medical issue, Include name of patient. If tragedy, cannot be loss of home due to foreclosure, loss of job or divorce.

In the case of a medical condition, what is the time-frame for medical treatment and recovery? (Please provide a letter from the patient’s doctor detailing diagnosis, treatment, length of treatment and location of treatment(s). Letter must be on letterhead and include medical diagnosis form.)

Have you received assistance from the Falmouth Service Center (FSC) such as for food, financial aid or clothing? YesNo

May we contact FSC for a referral? YesNo

Do you have health insurance: YesNo
If yes, name of insurance provider:

Who are the employers of the parent(s) / guardian(s)?

Is/Are the employer(s) providing paid leave, and for how long?
If not, what is the loss of income due to loss of work?

What are your current financial issues?
Please explain how you would utilize our financial assistance if it were to be provided:

By checking the box below and submitting this application, I/we are confirming that all of the statements above have been answered to the best of my/our knowledge. I/we understand that WFFF is entitled to reimbursement of aid should WFFF find parent(s)/guardian(s) have knowingly provided deceiving and/or false information.