Step 1 of 7 - Select a Grant 14% Please select the grant(s) for which you are applying:(Required) Children and Families Financial Assistance FundUp to $2,500 annually. Tailored for each family and their journey. Examples include: bills, medical expenses, lodging during hospital stays, funeral expenses, etc. Urgent Need FundUp to $100 annually. Meeting the most immediate needs of families facing the overwhelming task of caring for a child with a life-limiting illness. Examples include: gas cards, transportation vouchers, grocery cards, gift cards for meals, etc. Counseling and Self Care FundUp to $500 annually. Funding for self-care for those with a child facing a life-limiting illness. Examples include: counseling fees, therapy sessions, Yoga for Caregivers and gym membership or passes. Person Requesting the FundsName First Last Relationship to the Child or Family: Self Medical Professional Parent or Guardian Family Member/Relative Other Other: Is the family aware of the application? Yes No Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email Phone Family InformationParent or Guardian(Required) Relationship to Child(Required) Name First Last Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email PhoneNumber of Siblings: B Brave Child's InformationName(Required) First Last Gender(Required) Female Male Date of Birth(Required) MM slash DD slash YYYY Has this family ever received prior funding from B Brave?(Required) Yes No Medical InformationPrimary Diagnosis Approximate Diagnosis DateMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Is there a medical reason for funds to be distributed quickly?(Required) Treating Medical Professional InformationName First Last PhoneEmail Hospital or Treatment Facility Your StoryPlease briefly describe the child’s history with their illness:Please briefly explain why the grant program(s) you selected is most applicable to you:Please briefly describe the specific need for funding, as well as the dollar amount(s) you would like to request:Name of Treating Medical Professional: Applicants Name First Last Δ
