Project 12-04 Family Grant Application

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Project 12-04 understands the complexities of raising a child with a rare genetic condition.

Our hope for this grant is to help families who may experience financial burdens while caring for their child. These funds could be put towards specialized medical equipment, adaptive toys, prolonged hospital stays, home renovations, or unexpected needs.

Project 12-04 wants to help. In order to be considered for this family grant, please fill out the form below including how this grant would be benefiting your child and family. If you have any questions, please contact: info@project1204.com.

All information provided in this application will only be used to evaluate grant candidates and shall not be disclosed to third parties for any reason. Project 12-04 will abide with all applicable federal and state laws and regulation regarding privacy including any applicable HIPAA requirements. Any question regarding use of personal information by Project 12-04 or this application should be addressed to Project 12-04 11350 Parkview Drive Becker, MN 55308. This grant is available for applicants within the United States.

Email *

First name: *

Last name: *

Address: *

City: *

State: *

Zip code: *

Cell phone number: *

Child's first and last name: *

Child's date of birth: *

YYYY

Child's age: *

Name of your child's genetic condition: *

Amount of funds being requested: *

$100-500

$500-1,000

Other:

How would this fund be benefiting your child and your family? Please provide as much information as possible that will assist us in evaluating your request: *

Are you interested in being featured on Project 12-04’s platform? If you marked yes, we will reach out to you by the email you provided for further discussion.
*

Yes

I have read and understand the guidelines of this application. I hereby certify that all information provided is true and accurate. *

Yes

Required

Send me a copy of my responses.

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