Brave the Shave Request Form Brave the Shave is a helping hand to families affected by childhood cancer. This program has been developed to assist families in North Dakota, up to one year post treatment, regardless of financial status. Please fill out the following request form to be considered for Brave the Shave assistance from the Brave the Shave Family Fund. All requests will be reviewed on a first-come, first-serve basis and are subject to committee approval. For travel related requests, please allow 2 weeks for processing. Please mail our payments to your creditors rather than paying by phone or computer. It will prevent additional headaches for us. Thank you for your cooperation.Please enable JavaScript in your browser to complete this form.Brave the Shave - Family Fund - Step 1 of 6We are a new honoree family *NoYesNextName of Honoree *FirstLastHonoree Date of Birth *Email *Name of Parents *FirstLastName of ParentsFirstLastAddress *Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodePhone *Honoree's Diagnosis *Date of Diagnosis: *Is your child in active treatment?Radiation Therapy? *YesNoN/AIf no longer in active radiation treatment, what was the date of last treatment?Chemotherapy treatment? *Yes on ChemeotherapyYes on Oral ChemotherapyYes on ImmunotherapyNoN/AIf no longer in chemotherapy treatment, what was the date of last treatment?I give my permission to Brave the Shave (BTS) to take and publish my likeness using still or motion media (photo and/or video) for use by BTS in the promotion of electric cooperatives, BTS, and/or its subsidiaries, including its use on any BTS websites, the Brave the Shave website and in BTS publications, advertisements and signage. I understand and agree that BTS may, in its sole discretion, edit, crop, touch up or otherwise alter a photo containing my image to improve the picture quality, composition, contrast and for other purposes. Further, I understand and agree that I shall receive no compensation of any kind now or in the future for the use of my likeness in the photo. I understand that the photos taken remain the property of Brave the Shave for future discretionary use. *AcceptDeclinePreviousNextI am requesting the following assistance:Lodging assistance outside of Bismarck, ND. Lodging assistance is the only request that is approved for direct reimbursement to a family. Please fill out the following information for your stay at least 2 weeks prior to your trip for approval, make the payment yourself if possible, then send the receipt to Angie at [email protected].Other requestsPlease include a copy of each bill being sure that it has the date, company address, the requester's address and the bill total listed on it.Brave the Shave RequestI am requesting the following service(s):Message Therapy ServicesNutritional Care ServicesREACH ServicesI am requesting transportation assistance for medical care:Gas CardPreviousNextDate of Appointment *Location traveled to for medical care (Healthcare Organization, City & State) *Miles traveled (round trip) *Honoree's DoctorDeparture date *Date of return *How would this request be helpful to your family? *PreviousNextDate for Check-In *Date for Check-Out *Other RequestsIn your request, please list vendor and dollar amount, if applicable. (Bismarck Water Company bill for $123.00 If you are requesting an item, please include link. (Ipad - amazon.com)Request #1: *Dollar amount (if applicable)Attach a file for Request #1 Click or drag a file to this area to upload. Request #2:Dollar amount (if applicable)Attach a file for Request #2 Click or drag a file to this area to upload. Request #3:Dollar amount (if applicable)Attach a file for Request #3 Click or drag a file to this area to upload. Request #4:Dollar amount (if applicable)Attach a file for Request #4 Click or drag a file to this area to upload. PreviousNextComments/Questions for the Brave the Shave CommitteeThanks to the generous support of the community, we have been able to lessen the financial burden so families can focus on what’s most important — their child’s health. Remember to attach a copy of your bill if requesting financial assistance.PreviousWebsiteSubmit Like this:Like Loading...
