Application for Assistance

Instructions:
Please complete this application to apply for assistance from The RescYOU Group, Inc. If you need assistance in completing this application, please contact Shannon Leger @ (337) 256-1515.

* Denotes Required Field

Parent/Guardian/Caretaker Information

First name

Last name

Phone - (xxx) xxx-xxxx

Street Address

City

State

Zip

2nd Parent/Guardian/Caretaker Information

Check if Contact info is the same as above

First name

Last name

Phone - (xxx) xxx-xxxx

Street Address

City

State

Zip

Check if anticipatory (i.e. currently under hospice care)

Child Information

First name

Last name

Date of birth

Date of loss

Cause of death

Parish (if other is selected)

TRG serves a 10 parish region in Acadiana. If residence is outside this area, some services may not be available.

Religious Affiliation (if any)

School (if any)

Grade Level

Hospital (current or time of loss)

Funeral Home

Funeral Home Contact Person and Phone number

Please provide full name of siblings (if any)

Assistance Desired

Please check all applicable boxes

Financial for Funeral / Burial Expenses

Financial for Medical Expenses

Emotional Support for Parent(s) / Guardian(s) / Caretaker(s)

Emotional Support for Sibling(s)

Emotional Support (General)

Additional Information

Did you recieve a RescYOU Group Resource Folder?

Yes

Please provide any additional information you feel would be helpful.

Application Prepared By:

First name

Last name

Phone - (xxx) xxx-xxxx

Today's Date

Relationship to Child (if any)

We keep your personal information private and secure. Your information will be protected and treated with sensitivity. A consent form is required to release any personal information to a third party. All information is used for the sole purposes of The RescYOU Group, Inc. in providing the requested service(s).

Thank you for submitting your application. Someone will contact you soon.

Application for Assistance

Instructions: Please complete this application to apply for assistance from The RescYOU Group, Inc. If you need assistance in completing this application, please contact Shannon Leger @ (337) 256-1515. * Denotes Required Field

Instructions:
Please complete this application to apply for assistance from The RescYOU Group, Inc. If you need assistance in completing this application, please contact Shannon Leger @ (337) 256-1515.

* Denotes Required Field