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  • Date Format: MM slash DD slash YYYY
  • If you don't have an appointment yet, please select the clinic/city you wish to be seen.
    We understand this is a delicate situation. For your privacy select your preferred method of contact for us to reach you in the future.
  • Date Format: MM slash DD slash YYYY
  • Please tell us your story and why you need our help to pay for this abortion.
  • Financial-Aid Repayment

    We understand you are facing many financial hardships. We don't want to be just another bill. You will be given every opportunity to repay your obligation and therefore support others who also need assistance. Many clients repay in small amounts over long periods of time.
  • Please provide the amount of financial-aid you would like to receive. Keep in mind that we are a small grassroots organization with a small budget. We are only able give a maximum of 1/2 of the amount for any given procedure. Only with the repayment of your financial obligation can we continue to help other women in need.
  • By signing this form, I will honor my promise to repay this amount. I understand that my financial obligation will directly affect the Susan Wicklund Funds' ability to assist other women who also desperately need financial support.
  • This field is for validation purposes and should be left unchanged.