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Parent/Guardian's Name *

First Name

Last Name

Child's Name *

First Name

Last Name

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 Phone Number *

(###)

###

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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

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