"No act of kindness, no matter how small,
is ever wasted."
Aesop (620 BC - 560 BC)
THE IMPORTANCE OF LITTLE THINGS
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MISSION STATEMENT--NON DISCRIMINATION POLICY
MAKE DONATION
"QUICK CHECK PROGRAM" EXPLAINED
"QUICK CHECK PROGRAM" APPLICATION FORM
CONTACT US !!!
ITEMS & SERVICES TILT HAS PAID FOR
SUGGESTED WEBSITES
SUGGESTED WEB LINKS, DOCUMENTARIES, ARTICLES, PAMPHLETS & BOOKS
MEET OUR BOARD
Our "Quick Check Program" Application
(Please,
completely
fill out before submitting.)
*
Indicates required field
Requestor's Name
*
First
Last
Requestor's Title
*
Requestor's Email
*
Supervisor's Name
*
First
Last
Organization's Name
*
Organization's Phone Number
*
Organization's MAILING Address (Fill out Carefully!!!)
*
Line 1
Line 2
City
State
Zip Code
Country
Organization's PHYSICAL Address
*
Line 1
Line 2
City
State
Zip Code
Country
Requestor's Relationship to Patient
*
Patient's Primary TERMINAL Diagnosis
*
Describe Item(s) or Service(s) for Purchase. [Please EXCLUDE medical items, utilities, rent, mortgage, and funeral expenses]
*
Please Include Website Link(s) for requested Item(s)/Service(s) IF ANY.
*
Reason For Purchase
*
Anticipated Cost
*
PLEASE explain why Patient AND other Adult Family Members are NOT able to purchase the requested Item(s)/Service(s).
*
****Please Explain Why your Organization is NOT paying for the requested Item(s)/Service(s).
*
Please CERTIFY to the following by check-marking each statement:
*
Said item(s) and service(s) will be IMMEDIATELY PURCHASED with TILT's funds AND TIMELY DELIVERED to your patient.
ALL the information in your application is TRUE and ACCURATE.
For TILT's Grant-Writing Use Only:
*
Minority?
Female?
Male?
Requestor's Signature (Please Type)
*
Date of Request
*
Submit