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 AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest 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 AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest 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 DateMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Is 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
