| Home |    | Donations |    | Referrals |    |Member Sign-In|    | Contact Us |   

We are pleased to notify members of LRW Foundation that we have established supplemental health insurance policies. Insurance as follows:  Supplemental Cancer, accident, heart/stroke policies as well as Hospital intensive care riders.
Contact Us to find out what we can do for you.

Prior to acceptance of any application submitted, we require limited information in order to ensure protection of privacy. This protects the families right to privacy as well as false hopes of acceptance. Subsequent to the approval of an application, we will provide an additional form that must be completed and submitted directly from the applicant (child's parent/guardian).

Please complete the online application below in order to submit a request for support for a client/patient. This form may be duplicated. Please contact us at 440.466.0582 if you have any questions. Our fax number is: 440.466.0593. Our mailing address is: Lindsay Rowen Wenk Foundation, 1926 Barnum Road, Geneva, OH 44041.
 

Name of Professional:
Agency/Employer:
Title/Position:
Dates of acquaintance with applicant:
Address:
City:
State:
Zip Code:
Work Phone:
FAX:
E-mail:
Child's Age:
Diagnosis/Afflication:
Month/Year of Diagnosis:
Family's Annual Income:
Number of Children in home:
Family's Zip Code:
Please describe the family's needs:
Please provide a summary of the child's wellness history:
Please describe service(s) or product(s) desired:
Note: Estimates and/or support data will be required to complete the application. Original receipts will be required if the request is a reimbursement. AUTHORIZATION FOR THE RELEASE OF INFORMATION I hereby request and authorize the disclosure of information about me as described below:
Name:
Name of Company authorized to disclose the information::
Name of entity authorized to receive and use the information: Lindsay Rowen Wenk Foundation Description of the information that may be disclosed: The information that may be disclosed includes information deemed necessary to receive support from the Lindsay Rowen Wenk Foundation. The information will be disclosed only for the following purpose(s): At the request of the individual who initiated the request by signing this authorization. STATEMENTS OF UNDERSTANDING AND ACKNOWLEDGMENT: 1. I understand that the company authorized above to disclose this information can decline my application for support if I refuse to sign this authorization. 2. I understand that information about me provided to the named entity is no longer protected by federal privacy regulations and may be further disclosed. 3. I understand that I may revoke this authorization in writing at any time, except to the extent that action has been taken in reliance on this authorization. Revocation requests must be sent in writing to: [LRW Foundation, 1926 Barnum Road, Geneva, OH 44041]. 4. I understand that I am entitled to receive a copy of this signed authorization.
Input your name here as binding signature:
Effective Date:
	What is this? This test tells us you are real, not sending spam to us. Thanks. CAPTCHA Image Change Image Write the characters in the image above

Once we receive your initial online application information, we will contact you to discuss further the applicant's needs and any supporting documentation required to complete the application. Thank you!

back to top

The Lindsay Rowen Wenk Foundation is a 501-c3 Charity, Incorporated in the State of Ohio.
copyright © 2005-2015 Lindsay Rowen Wenk Foundation. All rights reserved globally.
designed and maintained by Design By J, LLC.