Name of Parent(s): _________________________________________________________
 
Name of Recipient(s): ______________________________________________________
 
Address (Must be a Monroe County Resident): ____________________________________
 
_______________________________________________________________________
 
Phone: _________________________________
 
Email:  _________________________________
 
What is the purpose for your ask for assistance? (Explain in a few sentences.)
 
_________________________________________________________________________
 
_________________________________________________________________________
 
How long has the recipient experienced these symptoms? ___________________
 
Do you have a lawsuit or settlement pending regarding this illness? _____________
 
What would donation be used for? (Medical expenses, treatment costs, gas/transportation, medical items needed at home, etc.)
 
________________________________________________________________________
 
________________________________________________________________________
 
Is there any other Information that would help to make the decision?
 
________________________________________________________________________
 
________________________________________________________________________
 
 
Please print and submit the application to Swing Fore Monroe County, Inc, 120 Madison Drive, Waterloo IL 62298 or email it to [email protected].