Wake Up & Lace Up is a 501(c)(3) non-profit organization that provides financial assistance to residents of Eastern Montana who have incurred unreimbursed out-of-pocket expenses (i.e. transportation, lodging, meals, etc.) associated with the treatment of a serious medical condition.

If you would like to request assistance for yourself or a family member or friend, please complete the following information and submit this application.  Contact information is located at the bottom of the page.

DATE:  _________________________________________________________________________

NAME (individual requiring assistance):   ______________________________________________

 ADDRESS:  ______________________________________________________________________

CITY, ST, ZIP:  ____________________________________________________________________

PHONE:  _________________________________    EMAIL: _______________________________

 REASON FOR REQUEST:  ____________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

 Name of person submitting request, if not the recipient:  _________________________________

Contact Phone:  ______________________________         Email:  __________________________
 

How did you hear about Wake Up & Lace Up?  __________________________________________

 Application may be submitted as follows:
EMAIL:             wakeuplaceup@gmail.com or reidgang@midrivers.com
MAIL:               107 Balsam Drive, Miles City, MT  59301
IN PERSON:     Call Cindy Reid at 406-853-3532 to make arrangements for delivery to any board member