Hope Foundation of the Mahoning Valley · Dreamcatchers for Kids

Contact Information

Are you a parent/guardian member of the child or a family/friend of the child?

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Parent/Guardian

Family/Friend

Name

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First Name

Last Name

Email

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Verify Email

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Parent/Guardian Phone

Family/Friend Phone

Parent/Guardian Address

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

Country

Family/Friend Address

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

Country

Child's Diagnosis

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Child's name

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First Name

Last Name

Child's gender

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Child's date of birth

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(mm/dd/yyyy)

Family's Estimated Annual Household Income

Tell us about your child and why you are making this DreamCatchers for Kids?

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Summary of why you are nominating this child.

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Complete & upload the required forms listed below

HIPPA & Monthly Medical Expenses-Fillable Form (PDF)

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Any additional information

Word or .pdf format

Any additional information

Word or .pdf format

Financial Agreement

www.hopemv.org/terms-conditions/

Submission Review

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I certify that I have read these Terms and Conditions, as stated here within this Programs Agreement, and attest that all the information provided in the Grantee’s application is true and correct. I further understand that any falsification or misrepresentation made in respect to this Agreement and its Application, or any accompanying documents, are subject to the forfeiture of funds, including but not limited to any other forfeiture of goods and/or services presented by the foundation.

Typing your name below will act as your digital signature.

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