Urgent Financial Assistance

Urgent Financial Assistance

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Applicant Details

Name
Address
Date of Birth
Sex
English speaking?
Race/Ethnicity. Please check all that apply:

Applicant Need & Supporting Documents

Click or drag a file to this area to upload.
Please note that The Journey Fund does not provide checks or Visa gift cards to applicants or pay medical bills. You can request a gift card for groceries or other basic needs or assistance paying a bill for non-medical expenses. ***If you request help with a bill, you must attach the bill to this application for payment.
Click or drag a file to this area to upload.

Legal

Authorizations
In order for TJF to process this application the applicant must consent to at least the first two authorizations. *** Please note, if you consent to having your photographs, quotes or videotape images to be used for publicity/publications, TJF would contact you directly to obtain photographs/videotape images. This consent does permit us to use quotes from this application in publicity/publications.
DISCLAIMER: By typing your name above, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application. I hereby certify that, to the best of my knowledge, the provided information is true and accurate.

Healthcare Representative Information

Name
Verifications
DISCLAIMER: By typing your name above, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application. I hereby certify that, to the best of my knowledge, the provided information is true and accurate.

*** Please note, your application will be reviewed within 30 days of the submission date. If you have any questions, please email chair of the application commiteee, Donna Banks, dbanks@nwmsonline.com. 

© 2022 The Journey Fund 501(c)(3)

253-200-5260

PO Box 26891 Federal Way, WA 98093

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