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
Gender:
Address
Address
Phone *
Phone
Alternative Phone Number: *
Alternative Phone Number:
What is your link to kidney disease?
Do you certify that the potential recipient of LAKE lives in the general area of Northeast South Dakota or Midwestern Minnesota?
SERVICES REQUESTED:
(*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):
Do you grant permission for us to talk to your care team or social worker?
Have you received LAKE services before?
Would you be willing to share your experience regarding kidney disease with others?