Family Assistance Request I am authorized to provide the information within this request form because I am either: the parent/legal guardian of the affected person(s), the affected person, or have been authorized by the affected person or their parent/legal guardian.(Required) Yes No Full Name of person completing this request form(Required) Name of injured or deceased(Required) Date of Birth(Required) MM slash DD slash YYYY Age(Required)Date of Crash(Required) MM slash DD slash YYYY Date of Death (if applicable)(Required) MM slash DD slash YYYY Location of Crash(Required) Details of Crash(Required)Family InformationMother's Full Name(Required) Home Address(Required) Phone(Required)Email(Required) Marital Status(Required) Father's Full Name(Required) Home Address(Required) Phone(Required)Email(Required) Marital Status(Required) Home address of injured or deceased (if different)(Required) Financial InformationHousehold Income (range is fine)(Required) Has there been a significant change in household income due to the incident?(Required) Yes No Please explainHas a GoFundMe been created?(Required) Yes No GoFundMe Link Was there a life insurance policy on the deceased?(Required) Yes No N/A Life Insurance Amount (list "n/a" if not applicable)Will you receive an insurance settlement? If so, what is the estimated amount?(Required) Funeral Costs (list "n/a" if not applicable)(Required) Funeral Home (list "n/a" if not applicable)(Required) Will you please give the funeral home permission to speak to us?(Required) Yes No N/A Counseling Information (if applicable)Do you need assistance with grief counseling? Yes No If so, do you have a pre-established counselor? Yes No If so, please list their name and contact information. Additional InformationHow did you hear about the Kailee Mills Foundation?(Required) If there are any other expenses or items, or questions you have, please list them here.(Required)CAPTCHA