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APPLICANT INFORMATION

FIRST NAME

LAST NAME

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CITYWESTERN NY CITY

STATEMUST BE NEW YORK

ZIP CODEWESTERN NY ZIP CODE

DATE OF BIRTH

ANNUAL HOUSEHOLD INCOME

ARE YOU OVER 18? IF NO, PROVIDE PARENT/GUARDIAN NAME.

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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 RESIDENCY AND DIAGNOSIS.

UPLOAD

The Just Breathe Foundation only offers assistance to residents of Western New York.

I confirm I am a Western New York Resident

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PARENT/GUARDIAN ELECTRONIC SIGNATURE