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BC Financial Aid ApplicationChristy Joubert2023-07-28T01:44:56+00:00

Unity Outreach Financial Aid Application

We strive to help everyone in need, if not financially at least with referrals to help meet the need. As we are a non-profit organization, our funds come from community donations and fund raising events. We work diligently to make those funds meet as many needs as possible. If you have questions or issues completing this application, please contact Sherry 904-955-5045 or Peggy 904-571-1658

Name *

Name

First

Last

Date of birth *

Address

City

State/Province

Zip/Postal

Country

Phone

Email *

Purpose of request? Briefly describe current need for assistance. *

Upload copies of invoices or bills you are requesting assistance for

Maximum file size: 209.72MB

2. Do you have an immediate need?

yes

3. How were you referred?

4. Do you have income?

yes

5. Do you currently receive any assistance?

yes

6. Have you applied for assistance elsewhere?

yes

If yes, where?

If yes, what were the results?

7. Do you have health insurance?

yes

If yes, what company?

If yes, what is your co-pay amount?

8. If you have insurance, does it cover prescriptions?

yes

If yes, what is prescription co-pay amount?

9. Doctor name and phone number?

Pharmacy name and phone number?

Treatment center name and phone number?

Signature *

Date *

If you are human, leave this field blank.

Insert/edit link

Enter the destination URL

URL

Link Text

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