Submit Online - Jim Meech Agri-Med Crisis Foundation

Farmer/Rancher Medical Crisis Nomination Form

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

Nominee Information

Date of Application *

Name *

Address *

City *

State *

ZIP *

Phone *

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

Email

Nominee’s Medical Crisis (please select) *AccidentHealth related

Date of Medical Crisis (month/day/year) *

Short explanation of medical crisis *

What are 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 operates *

Name *

Phone *

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

Email

Please check one option below: *I wish to remain anonymousI am OK with the nominee knowing I nominated them