Applicant

Helping Families and Children in Need

The Umbrella Club strives to find families and children in need who have been passed over by other more traditional organizations. We know what a contribution can mean in changing the lives of others. To qualify as a candidate, the potential recipient must meet certain criteria and complete an application. Our Good and Welfare Committee reviews the eligibility and needs of each candidate and eligibility is then determined.

Some of the criteria a potential recipient must meet are the following:

Legal Resident of Fairfield County, Connecticut
Identifiable need(s) that have gone unrecognized by other organizations
Physical/Mental/Emotional concerns that are not being properly treated by other agencies organizations

We welcome nominations from a variety of sources: Hospitals, Social Workers, Educational Systems, Religious Organization, Corporations and recommendations by our members.

Potential Recipient Application:

*All fields are required to be completed, if not applicable please enter n/a

Date of Submission*
MM slash DD slash YYYY
Person/Organization Making the Request*
Email Address*
Relationship to Recipient*
Address*
Home Phone*
Cell Phone*
How did you learn about the Umbrella Club?*
Member Name*
Potential Recipient's Name*
Age*
Have we ever helped this child before?*
Recipient's Diagnosis*
Description of Recipient's needs*
Treatments and Therapies receiving*
Description of the financial assistance or resources you are requesting*
If you are requesting financial assistance, please provide an estimate of the cost from the provider*
If you are requesting financial assistance, please provide an estimate of the cost from the provider*
Name/contact of the provider you contacted (attach a written estimate if possible)*
Name/contact of the provider you contacted (attach a written estimate if possible)*
Name*
Address*
Phone*
Email*
Will any part of this item be covered by insurance?*
- Yes
- No
If yes, what is the total cost?*
How much will insurance pay?*
Insurance Carrier Name*
Insurance Policy Number*
Please indicate if any assistance is being received or will be received from any other foundation, agency, or fundraiser (Go Fund Me)*
Please indicate if any assistance is being received or will be received from any other foundation, agency, or fundraiser (Go Fund Me)*
Employment Status Parent(s)/Guardian(s)?*
- Yes
- No
Primary Care Physician Name*
Telephone Number*
Hospital*
Are you currently working with an Advocate?*
- Yes
- No
Name*
Email Address*

Submit Via Email

If you, or someone you know, are in need of assistance, please feel free to submit a recipient nomination by emailing us with your story and needs.

Email Us

Applicant

Helping Families and Children in Need

Some of the criteria a potential recipient must meet are the following:

Potential Recipient Application:

Submit Via Email

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