Brave Family Nomination Form

Child's Name

First Name

Last Name

Child's Age

Child's Birthdate

YYYY

Child's Ethnicity

Child's Race

American Indian or Alaskan Native

Asian

Black or African American

Native Hawaiian or Other Pacific Islander

White

Two or More Races

No Response

Embracing Brave Chapter Closest to the Child

Child's Medical Challenge

How will this child benefit from receiving funds from Embracing Brave?

Why are you nominating this child for Embracing Brave?

Does this child have another page (Facebook, Go Fund Me, YouTube video, etc.) that we can get more information from? If so, please provide here!

Has the child received funds from any other organizations to date? If so, from where and when?

How did you hear about Embracing Brave?

Relationship to the child?

Nominator's Name

First Name

Last Name

Parent's Name

First Name

Last Name

Parent's Email

Parent's Phone Number

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