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 complications for us. Thank you for your cooperation

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 *

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 Services

How would this request be helpful to your family? *

Comments/Questions for the Brave the Shave Committee

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):