Family Fund Grant Application Requirements

Name of Child *

Date of Birth *

Name of Mother *

Mother's Phone Number

Name of Father *

Father's Phone Number

Parents' Emails

Siblings' Names & Ages

Family's Address

Address Line 1Address Line 2CityStateZIP/Postal CodeCountry

Diagnosis

Age of Diagnosis

Date of Diagnosis

Attending Physician

Treating Hospital

Hospital City/State

Social Worker

Social Worker's Phone

Social Worker's Email

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

Family Fund Contacts:

Kristie Becker Phone 701-214-7463
Taner Ohlsen Phone 701-527-7013