NICU Assistance

Are you in the right place?

This application should be filled out in these situations:

Child is currently in the NICU.
Child has been released from the NICU within the last six months.
Child has been transferred from the NICU to PICU or other specialized department.
Child was in the NICU, released home, and readmitted.
If child was released home from NICU or similiar, then readmitted, within six months of the release date.

Important: Must Read

All applications require a verification from a third party. An application will only be reviewed with a verification.

Please click here to find out more about what constitutes a verification.

We require information on income in a number format (this can be a range if needed). The use of N/A, unknown, or nothing, and other similar terms will not be accepted and your application will be closed.

"*" indicates required fields

Name of Person Seeking Financial Assistance*

Please put parent or guardian name not child's name

First Last

Name of Person Filling Out Application (if different than above)

First Last

Who is Filling Out This Form?*

Parent

Social Worker/Case Manager

Other

If you selected other above, please explain who you are

How Did You Find Out About This Program?*

Email*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Phone*

Hospital name*

Hospital Address*

Street Address Address Line 2 City State ZIP Code

How Many Miles Away Are You From Hospital?*

Please list the miles you live (one way) from the hospital

Child's Name*

Baby's Date of Birth*

Baby's Expected Release Date*

Number of People Living in the Household*

Total Household Income from Last Year*

Expected Total Household Income for Current Calendar Year (from all sources)*

If you have additional information that may help us make a determination regarding your application, such as large outstanding bills which would show financial hardship, please list those circumstances here (example: phone bills, electricity bills, medical bills, bank or checking statements, etc.)

How Much Are You Requesting from The Colette Louise Tisdahl Foundation?*

Expenses you plan to cover with these funds (please be as detailed as possible)*

Upload any applicable files

Max. file size: 50 MB.

Anything else you would like us to know in order to make our decision?