Family Fund Grant Application Requirements

Name of Child *

Age

Name of Mother

Mother's Phone Number

Name of Father

Father's Phone Number

Parents Emails

Siblings Names & Age

Family's Address

Address Line 1

Address Line 2

City

State

Zip Code

Diagnosis

Age of Diagnosis

Date of Diagnosis

Attending Physician

Treating Hospital

Hospital City/State

Social Worker

Social Worker's Phone

Social Worker's E-mail

This written agreement and following legal guardian‘s signature(s), allows Brave the Shave members to contact this families’ social worker and/or physician.

Legal Guardian Signature

Name

Family Fund Contacts:

Kristie Becker Phone 701-214-7463
Taner Ohlsen Phone 701-527-7013
For more information go to [email protected]

Family Fund Contacts:

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