Aid Applicants Must Meet These Qualifications

Must have children under the age of 18 (or still in high school).
Must have recently been diagnosed with a serious
illness, injured in an accident or facing a tragedy.
Experiencing financial hardship.
Must provide a referral from a physician in cases of medical crisis.
Must provide a referral from the Falmouth Service Center.
Is not receiving financial assistance from a third party (i.e.: workers compensation).

Required Written Information

Letter or email from the treating doctor (on Doctor’s
letterhead) providing diagnosis/treatment & services
needed/length of treatment. Please provide a copy
of the medical/insurance diagnosis form.
Name and social security number of Head of
Household.
Copy of the family’s rent or mortgage statement.
PLEASE NOTE: If the family’s medical issue is not
within the first two months of diagnosis, and
the financial issues are going to be long-term, you
may be asked to visit the Falmouth Service Center
for a referral to Wings For Falmouth Families (WFFF).

Questions:
Contact Joanne Bayles
Email:

*We will not begin to process your application until all necessary paperwork is provided to Wings For Falmouth Families.

*Wings for Falmouth Families retains the right to ask for additional supporting materials as necessary.

Date:
Parent(s)/Guardian's Names:
Email address
Street Address:
Town:
Contact Name:
Home Phone:
Cell Phone:
Best Time to be contacted:
Falmouth Resident?:	Yes No
Employed in Falmouth?:	Yes No
Number of Children:
Names of Children:	Age:
	Age:
	Age:
	Age:
	Age:
	Age:
1. Please explain medical crisis or tragedy currently experiencing. Include name of individual if medical issue. If tragedy, cannot be loss of home due to foreclosure, loss of job or divorce.

2. In the case of a medical condition, what is the timeframe for medical treatment and recovery? (Please provide a letter from the patient’s doctor detailing diagnosis, treatment, length of treatment and location of treatment(s). Letter must be on letterhead and include medical diagnosis form.)

3. Have you worked with the Falmouth Service Center (FSC) for assistance with food and housing expenses?
	Yes No
Can we contact the FSC for a referral?	Yes No
4. Do you have health insurance? If yes, what company, what are the estimated uncovered expenses?

5. Who are the employers of the parent(s) or guardian(s)?

6. Is your employer providing paid leave, and for how long? If not, what is the loss of income due to loss of work?

7. What are your current financial issues? Please explain how you would utilize our financial assistance?

All the statements above have been answered to the best of my/our knowledge. I/we understand that WFFF is entitled to reimbursement of aid should WFFF find parent(s)/guardian(s) have knowingly provided deceiving information.
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