NICU Assistance

This form should be used by parents or guardians of NICU babies

As of November 1, 2020, acceptable verification has to fall under one of the following categories:

A healthcare provider verification form submitted online on our website at www.colettelouise.com that is appropriately filled out by the third party with complete name, title, and contact information.
A healthcare provider writing a letter on the appropriate letterhead and emailing said letter directly to us at michelle@colettelouise.com. The email must come from whoever wrote the letter and it must be from their official work email and include their full name and contact information in either the letter or the email.
In cases of loss, documentation submitted or sent from either healthcare provider or parent applying that is official government or hospital paperwork. This may include a death certificate, the official paperwork that hospital completes for a death, or a detailed medical write up (not discharge paperwork) that shows the logo and contact information for the hospital or doctor as well as contact information for follow up.

"*" 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: 100 MB.

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