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Gabriella’s Smile: New Member Application Form

If you’re interested in learning more about our free support services for families affected by pediatric cancer, including becoming a member of our community, please complete the following application. A healthcare form will be automatically sent to your hospital social worker to the email address you provide below.

Once submitted, a member of the Gabriella’s Smile Foundation team will reach out to you by phone or email. We’ll guide you through the next steps, provide you with any additional intake forms, schedule a one-on-one welcome meeting, and answer any questions you may have.

We’re here for you—and we look forward to connecting soon.

Programs and events at the Children’s Cancer Support Center are absolutely FREE.

Parent/Guardian's Name

First Name

Last Name

Child's Name

First Name

Last Name

Which program are you applying to?

Choose which program you wish to apply for.

Child's Date of Birth

MM

DD

YYYY

Birth Certificate

We require a copy of your child's birth certificate to verify we are providing assistance to the child's parent or legal guardian. Please email a copy of your child's birth certificate to grants@strongerthandipg.org

I agree

Parent Email Address

Social Worker or Case Manager Email Address

Parent Phone Number

(###)

###

####

Parent Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Check Mailed To (if different than above)

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Check Made Out To (if different than guardian)

First Name

Last Name

Child's Website or Care Page

http://

Media Release

I grant permission for Gabriella’s Smile Foundation and its representatives to use photographs of my child or myself, our names and my child’s story to inform families, volunteers, the media and the general public about Gabriella’s Smile Foundation and its programs, services and events. Such materials may be used in, among other items, promotional materials, newsletters or on the internet. If permission is granted above, I, for myself and my child, release all claims against Gabriella’s Smile Foundation and its representatives with respect to copyright ownership and publication, including any claim for compensation related to use of these materials.

I agree

I do not agree

I will email a photograph of my child to info@strongerthandipg.org

Medical Release

I authorize Gabriella’s Smile Foundation and its agents and representatives to contact the medical provider in order to verify my child’s DIPG/ cancer diagnosis. I authorize the above named medical provider to release to Gabriella’s Smile Foundation and its agents and representatives any information and medical records deemed necessary by Gabriella’s Smile Foundation to complete its verification of my child’s DIPG/ Cancer diagnosis. I acknowledge that Gabriella’s Smile Foundation will pursue and is entitled to restitution for a grant if it is determined that the information submitted on this application is false.

I agree

Heard About Us

I heard about Gabriella’s Smile Foundation through the following

Family

Parent of a child with brain cancer

Physician

Social Worker

Heard About Us (other)

I heard about Gabriella’s Smile Foundation through the following other method:

Alternatively, download the application and deliver manually to your medical provider by clicking here. Remember to submit the healthcare provider form along with the required documents and the grant application. Once complete, your healthcare provider must submit the application via email or fax.

Join our Community

Gabriella’s Smile: New Member Application Form

Gabriella’s Smile Foundation

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