Apply for a stipend

Please upload the diagnosis, ensuring it includes the physician’s letterhead.
Please provide an essay of at least 250 words detailing your story.
Stipend recipients are required to observe a 36-month waiting period prior to reapplying.

Name *

First

Last

Email *

Phone

Address

Address Line 1

Address Line 2

City

State

Zip Code

Tell us your story *

250 words minimum

Please upload documentation of your diagnosis *

Click or drag files to this area to upload. You can upload up to 3 files.

If possible, we ask that you provide medical documentation on official letterhead that is dated within the last six months.