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Halo Financial Assistance Fund

Let Unmask the Invisible Help Illuminate Your Path

To apply for a one time grant to support medical therapies, equipment, and expenses not covered by medical insurance, please complete the application below.

Contact Information

Name

First Name

Last Name

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Address

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Address Line 2

City

State/Province

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Country

Referring Organization *

If none, please fill in with N/A

Referral's Name

First Name

Last Name

Referral's Email

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Referral's Phone Number

Briefly Tell Us Your Story & Include Your Social Media Links