The Meaghan Michelle Hicks Fund for Unmet Needs

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Before filling out this application, please be sure to carefully read the requirements to be a recipient of this fund below. Failure to read ALL information below will result in delay of your application review.

-Applicants must be a PH patient.
-Funds must be used for non-medication, immediate needs (cannot be used to purchase medications).
-Applicants must have a PayPal account for disbursement of funds.
-Applicants must provide PDF receipts for goods or services purchased within 30 days of receiving funds, screen shots and pictures of receipts cannot be accepted. If you do not provide receipts, you cannot be considered for a grant in the future.
-Applicants must agree to allow Team PH to share their name, photo, and a relevant blog to use to promote the Unmet Needs Fund.
-Applicants must agree to help spread the word about the Meaghan Michelle Hicks Fund for Unmet Needs and pay it forward by sharing information about the fund with 10 people, and working to fundraise to replenish the funds they received.

-Applicants who have received assistance from this fund four or more times will need to have demonstrated reliable communication with Team PH regarding the impact the funds have made in managing his/her chronic illness.

Please be detailed when filling out the application.

Email *

First Name *

Last Name *

Birthday *

YYYY

Which of the following best describes you? *

Asian

African American

Caucasion

Hispanic or Latino

Multiracial or Biracial

Native American or Alaskan Native

Native Hawaiian or Other Pacific Islander

I prefer not to answer.

Other:

FULL ADDRESS, City, State, Zip code *

Phone number where we can reach you *

We must verify that you have pulmonary hypertension

If you have another way to verify this, please add that information in the "Other Verification" section below.

What is your exact diagnosis type? *

What year were you diagnosed? *

Are you treated by a doctor for pulmonary hypertension? *

Yes

Other:

At what medical center are you treated? *

Who is your PH doctor or Specialist (Full Name)? *

What is their phone number? *

What is the name of your specialty pharmacy? *

Are you a member of a PH support group? *

Yes

If so, who is your support group leader? *

Would you like information on Team PH's virtual support group? *

Yes

Not right now

Are you interested in joining a Peer to Peer Group for one on one support? *

Yes

How did you hear about the Unmet Needs Fund? *

Tell us about your unmet needs

How can these funds help you with an unmet need related to your pulmonary hypertension

Please outline your unmet need in as much detail as possible. *

What, if any, other avenues have you explored to meet this need? *

What is your household income per month? *

How many people live in your household? *

Have you been a recipient of this fund before? *

Yes

If you have been a recipient in the past, please let us know what month and year. If you have not been a recipient in the past, please put "not applicable." *

If you have been a recipient before, were you able to fundraise to replenish the funds you received? *

Yes

I have not been a recipient before.

We require that you have a PayPal account, as this is how we disperse funds. Do you have access to a PayPal account? *

Yes

What is your PayPal account name or email associated with the account? *

Do you agree to send Team PH PDF receipts for items/services purchased within a month of receiving a micro-grant? *Screen shots and pictures of receipts cannot be accepted. If you do not provide receipts, you cannot be considered for a grant in the future.* *

Yes

Sharing Your Story

We will want to share your story and we ask you to share our relief efforts with those you know.

Do you agree to share your PH story with Team PH?

Yes

Clear selection

Do you agree to let Team PH share your name, hometown, and story with the public on our website and social media channels to help us spread awareness about the Unmet Needs Fund? *

Yes

Do you agree to "pay it forward" and personally ask at least 10 people to donate to our Unmet Needs Fund to help meet the needs of more PH patients? *

Yes

Do you agree to email your high resolution photo to tonya@teamphenomenalhope.org immediately after completing this application? See the high res photo below as an example. Please note we cannot use cropped photos or photos with filters from Snapchat, Instagram, etc. *

Yes

The Meaghan Michelle Hicks Fund for Unmet Needs is supported by:

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