Effective
immediatly all requests for funds must be made prior to performance of
the medical procedure.
Please print this form and send
to:
Mary
Freeland, RN
Phone: 623-694-8558 Fax: (623) 979-2775
e-mail: sklrnmary@aol.com
| Date:
________________________________ |
Nurse's Name: _________________________ |
| School District : ________________________ | School : ______________________________ |
| Address: ______________________________ | City, State, Zip : ________________________ |
| Telephone: ____________________________ | Fax : _________________________________ |
| Child's Name __________________________ | E-Mail: _______________________________ |
| Item requested: __________________________________________________________________ | |
| Rationale for need/intervention: _____________________________________________________ | |
| _______________________________________________________________________________ | |
| _______________________________________________________________________________ | |
| What prior funding resources have been considered?:____________________________________ | |
| _______________________________________________________________________________ | |
| _______________________________________________________________________________ | |
| Exact cost: $_____________ Document attached: __________ Document to Follow: __________ | |
| Make check payable to: ___________________________________________________________ | |
| Nurse's Signature: _______________________ Principal's Signature: ______________________ | |
| For Office Use Only |
|
| Request Approved :_______________ Check Requested: _____________ Check #: __________ | |
| Follow-up report requested: ______________ Funeral Home notified/date: _________________ | |
| Receipt received: __________ Follow-up report received: _________ AFDA Notified: ________ | |
| Denied: ____________ Reason: ____________________________________________________ | |