If this form is being submitted by someone other than the patient, I certify that I am authorized to act on behalf of the patient and provide/discuss their medical condition. If you are someone other than the patient, spouse, parent, or helath care provider a notarized Power of Attorney may be required for consideration of this application and discussion of a potential grant award.
As a secondary means of getting to know our applicants better, and in an effort to make the best decsions regarding where we distribute funds, our application process will include a virtual interview with the patient, caregiver, and/or other family members submitting this application. Doing so affords us the opportuinity to get to know you better, allows you to get to know us better, and provides the opportunity to connect in a manner beyond what is possible in a written application.