Skip to content

Search for:

Home
Get Help
About Us
FAQ
Partners
DONATE NOW
Facebook
FR

Application Formadmin2024-02-10T16:10:46+00:00

Request for Assistance

Referred By:

Must be a medical professional.

First name *

Last name *

Phone number *

Email *

Occupation *

Why, in your opinion, does this family require financial assistance? *

Child's Information:

First name *

Last name *

Street *

City *

Province *

Postal Code *

Date of Birth *

Sex *

Illness *

Mother's information:

First Name

Last name

Phone Number

Father's information:

First Name

Last name

Phone Number

Additional Information:

Preferred Correspondence Language *

English

French

Email Address *

Is the client on Social Assistance? (If yes, contact the case worker) *

As a family why are you in need of financial assistance from the Sick Children's Fund? *

Please indicate the items for which you need assistance:

Travel

Prescription Drugs (Prescription Required)

Please attach the prescription *

Choose File

Medical Equipment (Prescription or Doctor's Letter Required)

Please attach the prescription or doctor's letter *

Choose File

Other

Please specify: *

If accepted, what would be the preferred method for receiving the funds? *

Cheque

INTERAC e-Transfer

Unknown

Email Address for INTERAC e-Transfer *

By submitting this application, the FUND understands you are applying for assistance and you are also granting us permission to talk to the child's doctor, social worker, caseworker or any relevant party to determine the level of required assistance.

I understand and give my permission

Thank you for your message. It has been sent.

There was an error trying to send your message. Please try again later.

Contact

Monday - Friday: 9:00AM - 6:00PM
Closed Weekends and Holidays
P.O. Box 23103,
Moncton, NB E1A 6S5
(506) 853-0498
LSCF.NB@gmail.com

Quick Links

About Us
Programs
FAQ
Partners

Make a donation

You will positively impact families enduring medical stress. Six $20 donations will send a family to IWK for the day.

Donate Today

Facebook

Page load link

Go to Top