Medical / Funeral Expense
and Emotional Support Program

If you have experienced the loss of a young loved one and are in need of financial assistance for medical or funeral expenses or emotional support, The med Foundation would like to help. We have identified the financial and emotional support needed within our community for families who are dealing with expenses following the untimely death of a child and wish to ease that burden by providing a funds to offset the medical/funeral expenses.

To submit an application, please review the program guidelines and eligibility requirements first then complete the application form below. You will be contacted after the application has been submitted and reviewed.

Program Guidelines & Eligibility

Who is eligible to apply for and receive help?

How much money does the program award?

How are the funds disbursed?

Program Application Form

Submissions are not automatically approved. After submitting the form our board will review your application and a representative from The med Foundation will notify you if the application has been approved.

Medical/Funeral Program Application

Parental's Information

Mother's First Name

Mother's Last Name

Father's First Name

Father's Last Name

Mother's Phone #

Father's Phone #

Mother's Email Address

Father's Email Address

Address Line 1

City

State

Zip Code

Parish

Child's Information

Child's First Name

Child's Last Name

Child's Date of Birth

Child's Date of Death

Child's Gender

Physician's Name

Hospital or Facility Delivering Services

Funeral Home Name

Funeral Home Contact Person

Funeral Home Phone #

Additional Info

Assistance Requested

Do you have any additional children?*

Permission to include your Child’s full name on our website or advertised publicity?

Prepared by:

Preparer's Phone #

I have read and agree to the Privacy Policy