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Cortland County Burn Fund Inc. In Memory of Cristiana Marie Adams Mail Correspondence to: 66 Elm Street Elm Street, Cortland, New York 13045 The Cortland County Burn was first conceived in 1975 by the members of the Homer Fire Department as a memorial to of Christiana Marie Adams. Christiana died in a drowning accident in 1975 and was the daughter of an active Homer Fireman. On January 1, 1977 the Cortland County Burn was established with the full support of all the Fire Departments in Cortland County. The main purpose of the Burn Fund is of financial assistance to residents of Cortland County that have incurred medical expenses for the treatment of burns. The Burn Fund is supported by donations and/or memorials received from local fire departments and/or auxiliaries, service organizations, and individuals. Monies are available ONLY to residents of Cortland County or residents that are by a serviced by Cortland County Fire Departments AFTER all other insurance avenues have been exhausted, or in the case where there is NO Insurance at all. Should you find it necessary to use the assistance of the Cortland County Burn Fund, Inc. submit the attached application along with two(2) copies of all unpaid statements and mail to the following address: Cortland County Burn Fund Inc. In Memory of Cristiana Marie Adams Mail Correspondence to: 66 Elm Street Elm Street, Cortland, New York 13045 Your application will be reviewed by the Board of Administration and you will be notified of their decision. ---PAGE BREAK--- Cortland County Burn Fund Inc. In Memory of Cristiana Marie Adams Mail Correspondence to: 66 Elm Street Elm Street, Cortland, New York 13045 PATIENT APPLICATION FOR ASSISTANCE FORM D.O.B Sex: Phone Number City, Village, or Town County PATIENT INFORMATION HOW BURN OCCURRED: BODY AREAS BURNED: EXTENT OF BURNS (1st,2nd, or 3rd Degree): INSURANCE INFORMATION Name of insured: Relationship: Place of Name of Insurance Policy Number(s) Local Address of Insurance Company: If more than one insurance company is involved; please list information on back. Thank-you. IMPORTANT: BEFORE the Cortland County Burn Fund can be of financial assistance to you, ALL INSURANCE avenues must be exhausted. If these conditions are true, please enclose two(2) copies of ALL UNPAIND statements and mail to: Cortland County Burn Fund Inc. In Memory of Cristiana Marie Adams Mail Correspondence to: 66 Elm Street Elm Street, Cortland, New York 13045 Signature of Applicant/Parent/Legal Guardian ALL INFORMATION WILL BE HELD IN STRICT CONFIDENCE! Application Approved: ---PAGE BREAK--- Check(s) Issued