Apply For Financial Assistance or Medical Equipment

Release and Statement of Confidentiality In consideration for the receipt of any financial assistance or medical equipment that Under Calin's Wing, Inc. may provide to the applicant and/or the child applicant agrees on behalf of the applicant and the child to release Under Calin's Wing, Inc. and hold it harmless from any loss, liability, damage, cost or expense arising out of any claim or suits which may be brought or made which in any manner relates to the assistance or equipment provided to the applicant and/or the child as a result of this application. Under Calin's Wing, Inc. agrees to keep confidential all personal information, records, data, and files of any nature provided to it as a result of the applicant’s request for assistance or medical equipment (the “Confidential Matters”). The undersigned acknowledge and agree that all demographic information provided in the application is not included within Confidential Matters and may be used by Under Calins' Hand, Inc. for funding, grant, and other similar purposes.

Under Calin's Wing, Inc. agrees not to disclose any Confidential Matters without the prior written consent of the applicant, except when and if Under Calin's Wing, Inc. is required or otherwise compelled by a Court of competent jurisdiction to release such Confidential Matters.

Anti-Discrimination Policy Under Calin's Wing, Inc. of San Luis Obispo County is committed to a policy of non-discrimination and equal opportunity for applicants without regard to race, color, sex, creed, political affiliation, marital status, sexual preference, national origin, physical or mental handicap, or age, and does not show partiality or grant special favor to any applicant or group of applicants. All financial applications will be reviewed on a case-by-case basis, and the final determination will be made based on your eligibility, Under Calin's Wing guidelines, and the availability of funds.

Fill Out the Below Form

Does the Child Reside in San Luis Obispo County?
Child Full Name(Required)
Date of Birth
MM slash DD slash YYYY
Physical Address
Phone Number(Required)
Child's Primary Diagnosis
When Did the Child Begin Treatment for This Diagnosis
Primary Physicians Name? Hospital/organization? Address? Phone Number?
Specialist Physicians Name? Hospital/organization? Address? Phone Number?
Does the Child Have Health Insurance?
Parent or Guardians Full Name
Address
Phone Number(Required)
Email Address(Required)
Relationship to Child
Are You Willing to Share Your Child's Medical Records?
How can this money help you?
What would be the money spend on?
Phone
This field is for validation purposes and should be left unchanged.