CH Foundation Assistance Request
Please complete the following questions to request assistance through the Coulter Hampton Foundation.

All requests should be submitted two weeks in advance unless it is an EMERGENCY. This allows the board time to process your request and mail out payments that need to be made.

Copies of bills should be sent to stephanie@foamproducts.com with the subject line CHF CHILD IN NEED/ YOUR CHILDS NAME. Please be sure to include any information we will need to pay the bill such as pin/access numbers/ account numbers. Please make sure if you are photographing a bill that everything is legible.

If you do not hear from us... Please call Nikki Hampton 706-271-6534 to verify we saw your request! :)
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Email *
Name of Child Requiring Assistance *
Parent Name and Current Address Including Zip Code *
Current Phone Number *
Current Email *
What type of assistance are you seeking today? *
Please give us a brief paragraph about what your child's medical situation and how it relates to your request. *
I certify by filling out this application that I understand any funds received from the Coulter Hampton Foundation must be used for the reason requested. I understand that receipts must be provided for funds received from the foundation and provided in a timely manner. *
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