We are a new honoree family? *

NoYes

Honoree Information

Honoree First Name *

Honoree Last Name *

Honoree Date of Birth *

Contact & Family Info

Email *

Parent 1 – First Name *

Parent 1 – Last Name *

Address Line 1 *

Address Line 2

City

State

ZIP

Country

Phone *

Is your child in active treatment?

Radiation Therapy? *

YesNoN/A

Chemotherapy treatment? *

Permission for Brave the Shave to publish likeness in photo/video? *

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.

YesNo

Assistance Requests

Please include a copy of each bill…

I 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 requestsGas Card for transportation assistance for Medical Care

I am requesting the following service(s):

Massage Therapy ServicesNutritional Care ServicesREACH Services

Brave the Shave Request Form

Honoree Information

Contact & Family Info

Is your child in active treatment?

Assistance Requests

I am requesting the following service(s):