Aid Application Form

ONLINE FILL-IN FORM:  The fill-in form below must be completed to begin the process for a family to be considered for assistance.  Please submit this form and a member of Wings For Falmouth Families will contact you shortly.

REGULAR MAIL:  Alternatively, you may click this link AID APPLICATION pdf icon | Wings for Falmouth Families  for a printable PDF form below and mail to: Wings For Falmouth Families, P.O. Box 843, Falmouth MA 02541

Aid Applicants Must Meet These Qualifications

  • Must have children under the age of 18 (or still in high school).
  • Must have recently been diagnosed with a serious
    illness, injured in an accident or facing a tragedy.
  • Experiencing financial hardship.
  • Must provide a referral from a physician in cases of medical crisis.
  • Must provide a referral from the Falmouth Service Center.
  • Is not receiving financial assistance from a third party (i.e.: workers compensation).

Required Written Information

  1. Letter or email from the treating doctor (on Doctor’s
    letterhead) providing diagnosis/treatment & services
    needed/length of treatment. Please provide a copy
    of the medical/insurance diagnosis form.
  2. A photo ID of the head of household shall be shown
    to an Aid Committee member during the interview process.
  3. Copy of the family’s rent or mortgage statement.
    PLEASE NOTE: If the family’s medical issue is not
    within the first two months of diagnosis, and
    the financial issues are going to be long-term, you
    may be asked to visit the Falmouth Service Center
    for a referral to Wings For Falmouth Families (WFFF).
  4. Please understand that we cannot process your application until all of the necessary paperwork is provided to us and we retain the right to ask for additional supporting materials as necessary.

For questions regarding your application please contact Kristin Shearer: ktcapecod@aol.com or by calling (508) 388-7633 

Parent/Guardian Name:
Parent/Guardian Name:

Street/PO Box:
Town:
Zip Code:

Contact Name:
Email:
Home Phone:
Cell Phone:
Best time to be contacted?

Falmouth Resident? YesNo
Employed in Falmouth? YesNo

Number of Children who are age 18 yrs. or under:
Names and Ages of Children:
Name: Age:
Name: Age:
Name: Age:
Name: Age:
Name: Age:
Name: Age:
Name: Age:
Name: Age:

Please explain medical crisis or tragedy family is experiencing. If medical issue, Include name of patient. If tragedy, cannot be loss of home due to foreclosure, loss of job or divorce.

In the case of a medical condition, what is the time-frame for medical treatment
and recovery? (Please provide a letter from the patient’s doctor detailing diagnosis, treatment, length of treatment and location of treatment(s). Letter must be on letterhead and include medical diagnosis form.)

Have you received assistance from the Falmouth Service Center (FSC) such as for food, financial aid or clothing? YesNo

May we contact FSC for a referral? YesNo

Do you have health insurance: YesNo
If yes, name of insurance provider:

Who are the employers of the parent(s) / guardian(s)?

Is/Are the employer(s) providing paid leave, and for how long?
If not, what is the loss of income due to loss of work?

What are your current financial issues?
Please explain how you would utilize our financial assistance if it were to be provided:

By checking this box and submitting this application, I/we are confirming that all of the statements above have been answered to the best of my/our knowledge. I/we understand that WFFF is entitled to reimbursement of aid should WFFF find parent(s)/guardian(s) have knowingly provided deceiving and/or false information.

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