Nomination Parent Form

Please complete the form below

Parent's Name

First Name

Last Name

Parent's Phone Number

(###)

###

####

Parent's Email

Child's Name

First Name

Last Name

Child's Birthdate

MM

DD

YYYY

Siblings?

Please let us know how many siblings your child has. We love to support the whole family!

Child's Home Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Child's Medical Diagnosis

Share your child's medical journey

If selected what would the funds be used for?

Families have the option to allocate funds to their specific need. Some examples include medical bills, medical equipment, therapy costs, bucket list trips, dietary needs, specific remodeling for medical needs, etc. Families can choose anything that supports the wellbeing of the honorary child. Embracing Brave will pay the outside entity directly.

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

Is there a link we could follow to learn more about your child's challenges (Facebook, Go Fund Me, You Tube Video, etc.)

http://

Picture of Child

Please provide us with a link where we can find pictures of your child. This can be a link to Facebook, Google, Flickr, Shutterfly, etc.

http://

Nomination Parent Form

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