Fundraising Events

9th Annual Pennies for Nicoll Golf Classic

Monday, June 21st, 2010
1pm Shotgun

Country Club of Colorado

Information & Registration!
Family Support Program

PFN supports families who have children suffering with Sanfilippo syndrome and other MPS related disorders. Because there is no cure for Sanfilippo syndrome, the need for family assistance is astronomical. Although research for a cure is paramount, children living with the diagnosis need help immediately.

If you have a child with MPS and would like to apply for family assistance please review our assistance guidelines and then fill out the form below.

  1. Any child with a verifiable diagnosis of MPS is eligible for consideration.
  2. All sections of the application must be completed thoroughly and accurately in order for the selection committee to review the request. Failure to provide complete and truthful information is basis for denial.
  3. The selection committee meets once a month. Applications must be received by the10th of each month to be reviewed that month. Applications received after the 10th will be reviewed the following month.
  4. Applicants will be notified via e-mail when we are in receipt of their application.
  5. All applications will be reviewed on a case-by-case basis. Final determination will be made based upon other applications submitted and the availability of funds.
  6. All sections of the application will be verified thoroughly.
  7. Award letters and denial letters will be mailed to the applicants one day following the review date.
  8. Pennies For Nicoll Foundation may award one grant per family per year.
  9. Approved applicants will be required to submit a note affirming receipt of funds.
  10. Pennies For Nicoll Foundation reserves the right to deviate from the Guidelines when special needs arise.
  11. All information disclosed on the applications is confidential.

 

Assistance Application

  •  
    Name of Child:
  •  
    Diagnosis:
  •  
    Date of Birth:
    Date of Diagnosis:
  •  
    Description of Medical Needs:
  •  


    Financial Information

  •  
    Is the child covered under medical insurance?
    Yes
    No
  •  
    Is the child on Medicaid or on the Medicaid waiver waiting list?
    Yes
    No
  •  
    Is the child receiving assistance from any other financial assistance program?
    Yes
    No
  •  
    If yes, please list:
  •  
    Has there been any fund raising done to help relieve financial burden?
    Yes
    No
  •  
    If yes, please list:
  •  
    Do you have any plans for fund raising?
    Yes
    No
  •  
    Please explain both Yes and No:
  •  


    Parent Information

  •  
    Name of Parent/Guardian:
  •  
    Street Address:
  •  
    City:
    State:
    Zip:
    Country:
  •  
    Home Phone:
    Cell Phone:
  •  
    Email Address:
    Website:
  •  
    Total Family Income:
    Amount Requesting:
  •  
    Please explain your situation:
  •  


    Hospital Information

  •  
    Street Address:
  •  
    City:
    State:
    Zip:
    Country:
  •  
    Hospital Phone:
    Hospital Fax:
  •  
    Social Worker Name:
  •  
    Street Address:
  •  
    City:
    State:
    Zip:
    Country:
  •  
    Phone:
    Fax:
  •  
    Email Address:
  •  

    If application is approved, where would you like us to send the check?

  •  
    Name:
  •  
    Street Address:
  •  
    City:
    State:
    Zip:
    Country:
  •  
    I agree

    By checking "I agree", you testify that you have read, understand and are abiding by our applicant criteria and guidelines for family assistance. You swear that the information submitted to the Pennies For Nicoll Foundtion will be verified. You further understand that any false information submitted will result in denial of application and any future consideration.

  •  

 

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