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Family Assistance Grant Application
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Address
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Gender
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Grant Request
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Child's Name:
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Family Assistance Grant Request Fill-in Form
Have you received assistance from any other organization in the last 6 months?
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Yes
No
Email
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Child's Date of Birth:
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Child's Diagnosis
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Child's Social Worker
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Social Worker's Phone Number
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Does Child Have
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Facebook page
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Thank you for contacting us! If needed, you will hear back within 48-72 hours.
Physician Phone Number
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Parent/Guardian
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Phone
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If Yes, please provide organization,amount and date received. If No just enter N/A
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Date of Diagnosis
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I give permission to use my child's information suach as name, age, diagnosis or social media site on their website, Facebook page or any marketing materials.
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yes
no
Child's Physician
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Social Worker's Email
*
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