Family Support Application

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Parent/ Guardian name:*

Last name *

Email*

Phone*

Multi-line address

Country/Region*

Address*

Address - line 2

City*

Zip / Postal code*

Child's name *

Birthday

Month

Day

Year

Hospital/ Clinic *

Primary Physician/ Specialist name*

Social worker or hospital staff email*

This wil be used to have the social work or hospital staff fill out a form. This is required.

Does this child have a rare genetic diagnosis?

Yes

Medical Condition / Diagnosis

Brief Description of Child's Medical Needs/ Challenges*

Type(s) of support that would be most helpful at this time (check all that apply):*

Emergency financial assistance

Travel or lodging support

Utility or housing assistance

Food or daily living support

Other

Type of Assistance Requested*

Financial assistance

Make memories

Other

Briefly explain why your family is seeking support from Nate's Light Foundation*

Additional context you believe would be helpful (optional):

I confirm that the information provided is accurate to the best of my knowledge. I understand that submission of this application does not guarantee assistance, but it allows Nate's Light Foundation to evaluate how we can help*

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Nate’s Light Foundation is dedicated to supporting children with medical challenges and their families. Please fill out this application so we can better understand your needs and how we can help. All information is kept confidential.

727-744-5129

info@nateslight.org

Accessibility Statement

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