Need Based Membership

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.

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)
Date of Birth(Required)
Your Address(Required)
Please select the membership type you are applying for:(Required)
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.
Please share any special circumstances that may not be demonstrated in your application or supporting materials that you would like considered with your application.
Please upload documents showing your current financial situation for review here.
Drop files here or
Max. file size: 500 MB.
    Code of Conduct(Required)
    Consent(Required)
    Primary Applicant Signature(Required)