CHRISTIAN
SCIENCE NURSING CARE ENDOWMENT
SOUTHERN
CALIFORNIA
APPLICATION
FOR FINANCIAL ASSISTANCE
Date
prepared _____________________
Note:
Applications
will be considered that have been fully answered Our desire is to offer
financial assistance to students of Christian Science who are expecting and
working for spiritual healing and have very limited sources to pay for nursing
care. The information presented will be held in strictest confidence and will
be verified. This application must be signed by the applicant or by person
submitting the application for the applicant, and by the facility
administrator or by nurse providing the services. The financial data on the
reverse side must be completed for the application to be processed. Each
request is handled on an individual basis. The information provided will
help determine the amount of assistance required.
General
Information about the Applicant
Name:
________________________________________________________________________________
Address:
______________________________________________________________________________
City
___________________________________________ State_____________ Zip
__________________
Telephone:
( )
______________________ E-mail:
_____________________________________
Mother
Church Member ___Yes ___No
Branch
Church Member of
________________________________________________________________
Is
a Journal-listed Christian Science Practitioner working for you?
__Yes
__No Telephone number: (
) _______________________________
How long have you resided in southern California?
______________________________________
Are
you a:
__
Journal-listed Christian Science Practitioner?
How many years?
__
Journal-listed Christian Science Nurse?
How many years?
Would you please give two references (not family members) who are members of
The Mother Church,
and
who are acquainted with your life and work as a Christian Scientist:
Name:
_____________________________________________________
Telephone ( )
Name:
_____________________________________________________
Telephone ( )
FINANCIAL
ASSISTANCE
How
much are you able to pay of your monthly care cost?
How
long can you make these payments? _____________
Are
family members able to assist with these costs? ____ If so, how
much? __________
Are
you able to receive assistance from your Christian Science Association? ____
If so, how much? _______
Are
you able to receive assistance from your Church's care committee? ____
If so, how much? _______
How
much assistance are you requesting? __________
INFORMATION
ABOUT ACCREDITED FACILITY OR JOURNAL-LISTED NURSE PROVIDING HOME CARE
Name
of facility or nurse providing care:
______________________________________________
Telephone
( )
Address
Date
when nursing care commenced, or entered CS facility:
___________________________
Name
of person submitting this application (if not patient):
_____________________________
Telephone ( )
Relationship
to patient _________________________________
Date
Signature
____________________________________________________________________
TO
BE COMPLETED BY THE FACILITY WHERE PATIENT IS RESIDING OR BY THE NURSE
PROVIDING HOME CARE
Applicant's
level of care ___________________________________________________________
Total
monthly cost
What
portion of the total monthly cost is attributable to nursing?
Is
the facility depending upon Medicare? ___ Yes ___ No
MediCal? ___ Yes ___ No
for this patient?
In
the judgment of the facility or nurse, is patient radically relying on
Christian Science? ___ Yes ___ No
Signature of the facility administrator or nurse
Date
___________________________
P.O.
Box 2895 - Seal Beach, CA 90740 - CSNurscare@aol.com
(714) 687-5313
