The traceBRAVE Foundation Application

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The traceBRAVE Foundation provides financial assistance to families with a child with Type 1 Diabetes, infant to age 21, or college students to age 24. Please respond to each question as accurate as possible and provide as much information as possible to receive consideration for financial assistance. All applications will be carefully reviewed and considered and awards will be based on funds available. Employment status and annual household income do not automatically exclude one from consideration for assistance. *must be 18 years of age and a U.S. resident*

Email *

Name *

Name of child with Type 1 *

Age of child with Type 1 *

Email address *

Address and phone number *

Employment Status *

Full-Time

Part-Time

Contract

Seasonal

Other:

Annual Household Income range (before taxes) *

Less than $35,000

$35,000-45,000

$45,000-55,000

$55,000-65,000

$65,000-75,000

$75,000-85,000

$85,000-95,000

$95,000 and above

Household size *

1 person

2 persons

3 persons

4 persons

5 persons

6 persons

7 persons

8 persons

9 or more persons

Category of Needs (check all that apply) *

Insulin

Medical Supplies

Financial support

Food supplies

Diabetes Camp

Required

Statement of Need (please be specific and provide the dollar amount for your need) *

Disclaimer

The traceBRAVE Foundation reserves the right to grant or deny any application of need at any time, for any reason, and to supplement or amend application information requests at any time, for any reason. The traceBRAVE Foundation reserves the right to request proof of income from an applicant or parent/guardian of the applicant in need. The traceBRAVE Foundation does not and shall not discriminate on the basis of race, color, religion (creed), gender, age, national origin (ancestry), disability, marital status, sexual orientation, or military status in any of its activities, operations, or donations. This includes but is not limited to the approval of an application for assistance with medical supplies, insulin, financial support, or food supplies. The traceBRAVE Foundation shall maintain an applicant’s confidentiality and shall not share or supply an applicant’s information.

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