Application for Assistance Name of Student: Grade: Age: Date of Birth (ex. 01/01/90: Address: City: State: Zip: Phone: Fax: Email: Name of School: Address: City: State: Zip: Phone: Fax: Email: Current MACCS Health Services Client: Yes No Type of Assistance Requested: Services: Yes No Nature of Service: Financial: Yes No Indicate Amount: Reason for Request: Hardship Academic Endeavor Cultural Endeavor Discuss in detail the nature of the request and how assistance from the MACCS Children's Fund will be utilized:
