Parent / Guardian Assistance Request

12457541-friends4michael

Your Social Worker has completed a form requesting assistance from the Friends4Michael Foundation. The information below is required from the Parent or Legal Guardian of the patient in order to receive consideration for financial assistance. The Friends4Michael Foundation strives to process these applications within two business days of receipt. Please fill the fields below to complete the application submitted by your Social Worker.

Parent / Guardian section of Family Assistance form

  • PARENT / GUARDIAN INFORMATION

  • First & last name of patient's parent or guardian to whom assistance should be paid.
  • The Social Worker's number may be substituted if the parent or guardian does not have a phone available.
  • In submitting this form, I acknowledge and agree as the parent or guardian of the minor child/patient that the information submitted herein is accurate, true and complete. I further acknowledge and agree that by the execution of this application I am granting the F4M Foundation, its Directors and Officers permission to contact the medical provider(s) to confirm the foregoing information. I further acknowledge and agree that any and all sums received from the F4M Foundation by the above named shall be used solely for the purposes specified in this application. By submission, I agree to indemnify & defend the F4M foundation, its Directors and Officers against any cost, claims, or expenses, including attorneys' fees arising out of any breach of this agreement.