Family Support Application

Parent/Guardian name

Last name

Phone

Multi-line address

Country/Region

Address

City

Zip / Postal code

Child's Name

Birthday

Month

Day

Year

Medical Condition / Diagnosis:

Date of Diagnosis

Month

Day

Year

Primary Physician / Specialist Name

Hospital / Clinic

Brief Description of Child’s Medical Needs / Challenges:

Type of Assistance Requested

Financial assistance

Make memories

Other

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

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.