Submit a Referral

CRISIS READY. AG STRONG.

Complete the form below to nominate a farmer or rancher facing a medical crisis. The farmer or rancher does not have to ask for help themselves.

Standing with America’s farmers and ranchers when medical crisis strikes.

Farmer/Rancher Medical Crisis Nomination Form

The Foundation’s board will review all applications and respectfully reserves the right to decline requests for support.

Date of Application *

Name *

Address *

City *

State *

ZIP *

Phone *

Can a message be left at phone number given? *YesNoI do not know

Medical Crisis Type *AccidentHealth related

Date of Medical Crisis *

Short explanation of medical crisis *

Other than financial funds, what might be immediate needs of the nominee? *

Does 50% of nominee’s total income come from farming/ranching *YesNo(may be asked to provide proof)

County and State the nominee farm/ranch operation *

Name *

Phone *

Can a message be left at phone number given? *YesNo

Please select one *I wish to remain anonymousI am OK with the nominee knowing I nominated them

Be a lifeline for farmers and ranchers in need. Your tax-deductible donation makes a direct impact through our secure nonprofit platform.

Helping farmers and ranchers with immediate support within the first 30 days of an unexpected medical crisis.

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