Apply or Nominate - His Cavvy Foundation

Ranch Family Application Form

In this form you can apply for assistance or nominate a family for assistance. Please provide all the information you can about the situation. The more specific you are on the need of the family, the better. A lot of people doing a little makes a huge difference.

Ranch Family Information

Name(Required)

First Last

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone(Required)

Email(Required)

Children's Names & Ages

Ranch/Employer Information

Name of Employer/Ranch Name(Required)

Contact Person(Required)

First Last

Phone(Required)

Email(Required)

Applicant Information

Name(Required)

First Last

Diagnosis(Required)

Date of Diagnosis(Required)

Reason for Diagnosis (Please Select All that Apply)(Required)

Permanent Disability

Severe Injury

Chronic Illness

Diagnosis Resulted in (Please Select All that Apply)(Required)

ER Visit

Hospitilizaton

Other

If other, please explain.

Location of Treatment(Required)

Treatment Plan(Required)

Applicant Questionnaire

Please tell us a little bit about the ranch family/individual you are nominating, beyond the medical information already provided (if additional paper is necessary, please include applicants first and last name at the bottom of page):(Required)

Why are you nominating this ranch family/individual?(Required)

Are there any other avenues of financial assistance already in place for this family? Including but not limited to insurance, benefits, charities, etc.(Required)

If there is insurance coverage, what is your deductible?(Required)

If so, how much financial assistance is being provided from each avenue? Please be specific.(Required)

Donation Recipient

Person to Receive Donation(Required)

First Last

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone(Required)

Email(Required)

Release of Information

By submitting this application, I the undersigned, authorize His Cavvy Foundation to share its contents with its Board Members. Donations of funds by the His Cavvy Foundation are entirely discretionary. I understand that I am not guaranteed a monetary donation by submitting this application. The signatory represents and affirms that all information submitted in this application is true and correct. By signing your name electronically below, you are agreeing that your electronic signature is the legal equivalent of your manual signature on this application form.

Name(Required)

First Last

Date(Required)

Disclaimer

Personal information collected as part of the application process will become property of His Cavvy Foundation, and will be used by its Board Members for purposes of evaluating applicants. The Board Members have the final decision, and will evaluate each medical situation per incident, and its decision on each application is final.

This field is for validation purposes and should be left unchanged.