Financial Assistance Application : Support & Resources : National Bleeding Disorders Foundation

Please review the Financial Assistance Policy guidelines for NBDF National Chapters before submitting your application.

I have read and understand the Financial Assistance Policy guidelines

[OPTIONAL] Completion of this application will automatically register you with the West Virginia Chapter of the National Bleeding Disorders Foundation and place you on the mailing list.

I DO NOT wish to be placed on the mailing list.

Section I: Basic Information

Applicant's Name

(Parent’s name(s) in case of a minor.)

First Name *

Last Name *

Address

Country

Address Line 1 *

Address Line 2

City *

State/Province *

Postal Code *

Phone Number (Required)

(Where you can be reached for follow up questions.)

Email Address (Required)

Medical Insurance (Required)

Type(s) of medical insurance?

Do you have medicaid?

Employer(s), if applicable

(employer will not be contacted)

Job Title, if applicable

Employer(s) Contact Information

(employer will not be contacted)

Marital Status, if applicable

Spouse's Name, if applicable

Is spouse employed? If so, by whom?

The applicant is:

Person with a bleeding disorder
Parent of a minor child with a bleeding disorder
Other (write in below)

If Other, please describe

Type of bleeding disorder and/or other known medical diagnoses (Required)

Is the Person/Child with a bleeding disorder a patient of an HTC (Hemophilia Treatment Center)?

Have you or your family participated in any West Virginia Chapter programs or events such as camp, education weekend, Unite for Bleeding Disorders Walk, etc.? If no, please share barriers to participation. (Required)

Section II: Financial Assistance Request

Amount Request (Required)

West Virginia Chapter of NBDF is able to provide a maximum of $500 funding per household, which also includes claimed dependents.

Please describe your need for financial assistance (Required)

Describe how assistance will help resolve the current need. (Required)

Include as much detail as possible.

Please list any additional financial assistance requested from other organizations or programs for the current needs, dates, and outcomes of each request:

When are these funds needed? (Required)

Please be aware that West Virginia Chapter of NBDF may need between 7 to 10 days to process a request.

Have you applied for financial assistance from West Virginia Chapter of NBDF in the past? (Required)

If so, please provide the month and year.

Section III: Bill Payment Request

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Company Name/Establishment (Required)

West Virginia Chapter of NBDF cannot provide funding directly to individuals, but if approved, West Virginia Chapter of NBDF will pay a vendor directly. Please list your bill payment information below and include copies of bills with contact information wherever possible. Please review the West Virginia Chapter of NBDF Financial Assistance policy for more information.

Contact Name, if Applicable

Account Number

Company Mailing Address

Country

Address Line 1

Address Line 2

City

State/Province

Postal Code

Phone Company Contact Number

Website, when available

Supporting Documentation