LAKE AREA KIDNEY ENDOWMENT

PO BOX 1355

WATERTOWN, SD 57201

EMAIL: lake kidney1355@gmail.com

 

APPLICATION FOR SERVICES

Date
Date
Name of Applicant *
Name of Applicant
Address
Address
Phone *
Phone
Alternative Phone Number: *
Alternative Phone Number:
What is your link to kidney disease?
Realistically, how quickly are services needed?
(*Please mail/ email a copy of bill if applicable. Receipts or invoices are required for all requests prior to receiving assistance.)
$
$
Reason services are necessary (reasonably confirmed by neutral outsider, for example, social worker):