Medical Aid Request Intake Form | RESCUfoundation.org

Welcome!

This is the RESCU Foundation Intake Form for participants of Renaissance Faires, historical performances and other artistic events. Please fill out the form to the best of your ability, being as detailed and inclusive as you can.

Should you need to leave the form to gather more information or just continue at a later time, be sure to choose Save & Continue at the bottom of this application. You will receive an email with a link to return to later.

If you need assistance filling out this form call 608-207-8635.

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Qualification Questionnaire

Have you ever worked at a Renaissance fair, festival, or historical reenactment event?(Required)

Yes

Are you seeking financial aid or advocacy for a healthcare related issue?(Required)

Yes

Apologies, your need is not covered by RESCU.

RESCU Foundation, Inc. is committed to meeting the health and wellness needs of Renaissance fair/festival and historic event participants. To ensure we provide the best care to our community, we will not be able to assist with your needs at this time.

Participant Information

This is the section for your personal information.

Name(Required)

First Middle Last Suffix

Preferred Name

First

Date of Birth(Required)

Month

Day

Year

Gender

Relationship Status(Required)

Phone(Required)

Email(Required)

Permanent Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Temporary Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Client Health Issue

Provide a summary of your health issue.

Alternate Contact

Person whom you trust for medical data, or a separate contact we can use to contact you.

Alternate Contact's Name(Required)

First Middle Last

Alternate Contact's Relationship to Client(Required)

Alternate Contact's Phone(Required)

Alternate Contact's Email

I authorize RESCU to discuss or share any aspect of my case with my Alternate Contact.(Required)

Yes

Financial Information

Please fill this section out accurately and completely, to the best of your ability.

Do you have health insurance?(Required)

Yes

Financial Assistance Alternatives(Required)

Mark all that apply.

Applied for another charity or financial aid.

Crowd sourced fundraising (GoFundMe, etc)?

Received or requested a reduction on your bills.

Other

None of these apply.

If you have any Financial Assistant Alternatives (above), how much money have you raised so far?(Required)

What is your Annual Income NOT from Festivals and Faires?(Required)

This is the money you make in side hustles, week work, anything not at or for a Festival or Faire.

What is your Annual Income from Festivals and Faires?(Required)

This is the money you make in weekends or week work, so long as it is at or for a Festival or Faire.

Approximately, what % of your income is from Festivals and Faires?(Required)

Choose one

5 - 10%

15 - 20%

25 - 30%

35 - 40%

45 - 50%

55 - 60%

65 - 70%

75 - 80%

85 - 90%

95 - 100%

Participant Status(Required)

Choose one

Current Participant - actively working Festivals or Faires

Former Participant - no longer working Festivals or Faires

Do you receive any other monthly income (e.g. Social Security, Pension, Disability, Child Support)?(Required)

Yes

Contributing Household Member Annual Income

Do you have income from non-Festival or Faire employment?(Required)

Yes

What are your average monthly expenses?(Required)

Please enter a number less than or equal to 9999.

How many dependents do you have?(Required)

Please enter a number less than or equal to 99.

Do you have anything to explain about your income?

Participant Verification

Please fill this section out to the best of your ability.

Can you provide a copy of a Festival or Faire pass?(Required)

Yes

What was the last year you were a Pass-Holding Participant (volunteer, worker) at a Festival or Faire?(Required)

Please enter a number less than or equal to 9999.

What type of Pass-Holding Participant have you been at a Festival or Faire?(Required)

Employee

Volunteer

Manager

Owner

Ground Crew

Rides/Games

Security

Food Services

Crafter

Entertainment

Guild Member

Other

List the Festivals or Faires you have participated in, who you worked for, and the year you participated.(Required)

Faire/Festival

Year(s) Active

File Uploads

Please upload any important documents related to this case including bills, proof of income, most recent faire ID, etc.

Drop files here or

Max. file size: 128 MB.

Agreements and Finalization

Last four digits of your Social Security number

We may need this information when speaking with medical professionals about your case to talk down your bills or advocate on your behalf.Reminder: The RESCU Foundation follows HIPAA privacy laws. Your information will not be shared.

Please enter a number less than or equal to 9999.

Liability Release(Required)

I understand that RESCU is a non-profit organization seeking to assist participants of Renaissance Festivals, Faires, and other historical enactments in medical need. I am aware that RESCU holds my personal information in strict confidence in accordance with HIPAA guidelines. I understand that there are varying degrees of security when sending and receiving Personal Health Information (PHI). I assume full responsibility for how I send PHI and any consequences that may come from sending PHI in any and all mediums I choose.

I am aware that RESCU does its best to obtain a more favorable result for my situation, but there is no guarantee for success, also that RESCU is not assuming responsibility for payment on submitted medical bills. In consideration thereof, I hereby waive and release RESCU of any and all claims of any nature I and all other persons who may have a right to be involved on my behalf, including but not limited to any liability or claims of injury to my body or property or of my right to privacy, resulting from my application for assistance from RESCU. I also understand that RESCU does not assume any financial responsibility for any claims submitted through my submission of this form. I hereby certify that I have completed this form to the best of my abilities and that the statements provided are true. I understand that any material misrepresentation of statements in this application and in any other past or future communication about my situation with RESCU may disqualify me from assistance, and I understand that I may be required to pay back any financial assistance provided by RESCU before the misrepresentation was identified.

I agree voluntarily and without duress.

I agree to the Liability Release.

Digital Signature for Liability Release(Required)

By signing your legal name below, you are confirming your agreement to the above Liability Release statement.

Third Party Release of Information(Required)

I hereby authorize the RESCU Advocacy Program to speak on my behalf and to represent my interests when dealing with the financial burdens associated with my medical bills.

I authorize medical facilities, collection agencies, and any other businesses to fax, mail, or email any requested information or statements to RESCU Advocate(s) as requested.

I authorize the RESCU Advocacy Program to make any corrections to my contact information, including updates to my address and phone, and to advise medical or collections facilities of these changes.

This release is null and void two (2) years from the date signed agreed to.

I agree voluntarily and without duress.

I agree to the Third Party Release of Information.

Digital Signature for Third Party Release of Information(Required)

By signing your legal name below, you are confirming your agreement to the above Third Party Release of Information statement.

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