Need Assistance?

There are two options when applying for financial assistance: (1) fill out the electronic form below, or (2) print an application and mail it to our addressOnce we receive the completed application, including supporting documents, our board members will review and contact you with any questions. Our board votes on applications monthly, so if immediate assistance is needed, please contact us directly. Once our board comes to a decision, we will be in contact to discuss details. Please note: we do not provide payment directly to our applicants. Instead, we pay any financial obligations directly to vendors, doctors, businesses, and organizations.

The Just Breathe Foundation only offers assistance to patients and families in Western New York


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APPLICANT INFORMATION
FIRST NAME
LAST NAME
PREFERRED PHONE
STREET ADDRESS
CITY
STATE
ZIP CODE
DATE OF BIRTH
ANNUAL HOUSEHOLD INCOME
ARE YOU OVER 18? IF NO, PROVIDE PARENT/GUARDIAN NAME.
PERSONAL RESPONSE
WHAT ARE YOU SEEKING ASSISTANCE WITH?
ARE YOU CURRENTLY RECEIVING ASSISTANCE FROM ANYONE ELSE?Check all that apply
TELL US WHY YOU ARE SEEKING OUR ASSISTANCE.
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AUTHORIZATION

The Just Breathe Foundation ("the Foundation") is a non-profit organization committed to raising funds for persons with cystic fibrosis. The need for assistance and the number of requests received by the Foundation may exceed our resources. Consequently, neither the Foundation, its officers, directors, agents, nor employees represent that all applicants will receive funding from the Foundation. All grants are awarded on a case-by-case basis within the sole discretion of the board of directors. The application program has no exclusions as to race, ethnicity, gender, age, sexual orientation, or family characteristics.


BELOW, ATTACH DOCUMENTS THAT PROVIDE PROOF OF PRESIDENCY AND DIAGNOSIS.

UPLOAD
Date
ELECTRONIC SIGNATURE
Date
PARENT/GUARDIAN ELECTRONIC SIGNATURE
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