Financial Application | Living To Win

Instructions

Submit completed application along with supporting documents. Only completed applications will be considered for review by the Medical Advisory Team (MAT). Prompt notification made after determination.

How did you hear about Living to Win Foundation?*

Living to Win Event
Physician
Internet Search
Other

Name*

First Middle Last

Date of Birth*

Address*

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

Phone*

Email*

Employment Status

Full Time
Part Time
Self Employed
Unemployed
Student

Employer Contact Information

Next of Kin*

First Last

Total annual household income*

NMO Diagnosis:*

A physician's letter stating diagnosis date and current treatment will need to be uploaded.

Financial Assistance Required*

Treatment
Transportation
Rent/Mortgage
Utilities
Groceries
Automotive payment
Other

Has other assistance been exhausted including insurance? Please explain.*

Have you ever received financial assistance from L2W?*

Yes
No

Please provide the date*

Signature*

Date Submitted*

Medical financial assistance

Medical Financial Application

Instructions