Agnes Reynolds Jackson Fund Recipient Statistics

We ask that clinics receiving funding through the Aggie Fund provide the following information on patients receiving grants through our fund. If the patient has received previous grants through the Aggie Fund, please note this in the “Additional Notes” section.

Please be sure NOT to include patient names.

Clinic Name

Patient Information

Age

County & State of Residence

Race

No. of Children

No. of Previous Abortions

Is patient employed?

Yes

Is patient a student?

Yes

Grant Amount

Date of Services

Additional Notes

More Information for Clinics:

We ask you to fill out the statistics form on each individual, and to fill out the grant information sheet [PDF link here] and give it to the recipient.

Note:
If a patient needs help with transportation, please have them contact us directly.