Need Based Membership - Family Wellness Fargo

Complete the digital application below or print the Need Based Application and submit to the front desk, or via email at familywellnessfargo@sanfordhealth.org.

Once this application is complete and submitted, a member from our Member Relations team will reach out to you to collect the required supporting materials. If you have any questions, please contact familywellnessfargo@sanfordhealth.org or call 701-234-2400.

Need Based Membership Application

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Family Wellness Need Based Membership Application

As a commitment to our community, Family Wellness offers financial assistance to those with demonstrated financial need or extenuating circumstances. Family Wellness provides 25%, 50%, or 75% of the membership dues depending on each applicant’s situation. Family Wellness requires specific information about your financial situation as well as any special circumstance(s) that may warrant additional support. Once this application is complete and submitted, a member from our Member Relations team will reach out to you to collect the required supporting materials. If you have any questions about our need based membership application, please contact familywellnessfargo@sanfordhealth.org or call 701-234-2400

Primary Applicant Information(Required)

First Name Last Name

Date of Birth(Required)

Your Address(Required)

Street Address Address Line 2 City State ZIP Code

Email Address (required to inform of eligibility):(Required)

Your Phone(Required)

Please select the membership type you are applying for:(Required)

Individual

Family/Household

Family/Household with Childcare

Household Applicant Information

List all members living in your household below. Please note: If applying for a Family/Household membership, eligible members include two adults over the age of 18 residing at the same address and their dependent children through the age of 23 from the list below.

First Name

Last Name

Date of Birth

Gender

Relationship (Adult or Dependent Child)

Monthly Household Income

To determine the level of assistance, Family Wellness requires specific information about your financial situation as well as any special circumstance(s) that may warrant additional support. Fill in the monthly income dollar amount for each category.

Primary: Gross Wages, Salaries & Tips

Spouse/Partner: Gross Wages, Salaries & Tips

Social Security & Pensions

Child Support & Alimony

Federal or State Assistance (Examples: SNAP, WIC, Childcare, Medicaid, Rent/Housing, etc.)

Other (Examples: Student Loans, Grants, Family/friend contributions, etc.)

Medical Expenses

Total Income(Required)

Other Special Circumstances

Please share any special circumstances that may not be demonstrated in your application or supporting materials that you would like considered with your application.

File Upload(Required)

Please upload documents showing your current financial situation for review here.

Drop files here or

Max. file size: 500 MB.

PLEASE READ BEFORE SIGNING:

Primary Applicant Signature(Required)

First Name Last Name Date

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