Person Needing Assistance
Name

Date of Birth

Diagnosis

Address

City

State

Zip

Email

Phone

Person Requesting Assistance
Name

Relationship

Address

City

State

Zip

Email

Phone

Physician Information
Physician's Name

Address

City

State

Zip

Phone

Request Statement
List the type of assistance you are requesting. Please be specific. Please include all costs involved.

Other Questions
How many people live with the applicant?

What is the yearly family income?
(You may be asked to provide proof of income.)

Have you ever received assistance from Gracie's Hope?
Yes
No
How did you hear about Gracie's Hope?

Would you be willing to allow Gracie's Hope to use pictures and/or videos of the applicant to be used on Gracie's Hope website?
Yes
No
Would you be willing to allow Gracie's Hope to use pictures of the applicant to be used for Gracie's Hope brochures?
Yes
No

For HBOT Applicants Only
Has applicant ever received HBOT?
Yes
No
If yes, how many treatments?

Where were the treatments received?

Would you be willing to shoot before and after HBOT videos of the applicant to be used on Gracie's Hope website?
Yes
No

By clicking on the Send button below, you attest that the information you have entered above is truthful and accurate to the best of your knowledge.