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16 Big Oaks Street
Streamwood, IL 60107

Ph: (630) 587-6555
Ph: (630) 830-9781
Fx: (630) 587-6333

Apply for Help

Download the Apply for Help Document or fill out and submit the form below. If you do not have Microsoft Word, you can download the free Microsoft Word Viewer program.

Assistance Request Form
The following information will be used guideline for assistance, by the Nighthawk Foundation, Inc. The information will be kept confidential. All applications are subject to committee approval.

Name:
Address:	,
How Long:		Own Rent
Monthly Payment:
Telephone:
Child's Name:
Child's Birthdate:
U.S. Citizen:	Yes No
Disability/Illness:
Special Need:		(e.g. Wheelchair, chairlift, medications)
Assist. Needed: $		(include documentation & Dr./Therapist recommendation)
Monthly Income: $		(Gross, incl. savings, stocks, ins. polices, 401K, child support, etc.)
Social Worker:		Phone:
Other Organizations Providing Assistance:
Are you willing to help promote/attend a fund-raiser on your child's behalf? Yes No
Available Times:
Marital Status:	Single Married Divorced Widowed
Names and Ages of Children Living at Home:
Father/Guardian's place of Employment:
Address:
Telephone:
Mother/Guardian's place of Employment:
Address:
Telephone:
May we contact your employer(s)?	Yes No
Reason for assistance:	Please write a short paragraph explaining why your child needs the assistance of the Nighthawk Foundation.

Acceptance of this assistance constitutes permission to use your child's name and likeness for advertising and promotional purposes without additional compensation. Any items covered by Insurance / Medicare or Other Agencies will not be funded by the foundation.

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