Request Assistance From Team Quinn

Please fill out the following form to request assistance from Team Quinn.

Also visit the Resource Tab above for additional help.

Person Needing Assistance Information
Name*
Phone*
Email address*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Primary Caregiver Information
Name*
Phone number*
Email address*
Your relationship to the person needing assistance?*
What will the money be used for?*
Be specific if possible:
Hidden
Would the money be used to help pay for:
- Select All
- Prescription Cost
- Wheelchair
- Equipment / Supply Cost
- Caregiver Cost
- Other
Other reason*
How did you find out about Team Quinn?*
Electronic Signature of the person completing this application*
Qualifications:
• Virginia residency: Team Quinn helps Virginia residents battling ALS and is committed to helping those who are experiencing financial challenges as a direct result of the disease. A copy of the PALs Virginia driver’s license or government issued ID must be provided.

• Confirmation of Diagnosis: Team Quinn will call the primary contact person in order to collect certain information regarding the potential recipient’s medical condition and to obtain some background information. All information requested is strictly confidential and required for us to process the application. It is important for Team Quinn to assure our donors and others applying for assistance that due diligence is taken before assistance is granted.

• It is understood that the funds must be used directly and only for the needs and care of the person diagnosed with ALS.

• Disclosure: The potential recipient must be willing to disclose the name and telephone number of their healthcare provider who can verify the ALS diagnosis. The applicant must also complete and sign a HIPAA authorization giving their doctor permission to verify the ALS diagnosis and any other private health information necessary to Team Quinn.
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Application

Person Needing Assistance Information

Primary Caregiver Information

Qualifications:

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