To apply for financial assistance from Gabriella’s Smile, please complete the following application. Upon submission we will send a request to your health care provider for additional required information. Once complete, your healthcare provider must submit the application via email or fax. Submission of an application is not a guarantee of receiving a grant. Funds are limited and based on the availability. Once your application is approved, we will notify you via email.

Parent/Guardian's Name *
Parent/Guardian's Name
Child's Name *
Child's Name
Child's Date of Birth *
Child's Date of Birth
Phone *
Phone
Address *
Address
Check Mailed To (if different than above)
Check Mailed To (if different than above)
Check Made Out To (if different than guardian)
Check Made Out To (if different than guardian)
http://
Media Release *
I grant permission for Gabriella’s Smile Foundation and its representatives to use photographs of my child or myself, our names and my child’s story to inform families, volunteers, the media and the general public about Gabriella’s Smile Foundation and its programs, services and events. Such materials may be used in, among other items, promotional materials, newsletters or on the internet. If permission is granted above, I, for myself and my child, release all claims against Gabriella’s Smile Foundation and its representatives with respect to copyright ownership and publication, including any claim for compensation related to use of these materials.
Medical Release *
I authorize Gabriella’s Smile Foundation and its agents and representatives to contact the medical provider in order to verify my child’s brain cancer diagnosis. I authorize the above named medical provider to release to Gabriella’s Smile Foundation and its agents and representatives any information and medical records deemed necessary by Gabriella’s Smile Foundation to complete its verification of my child’s DIPG/Brain Cancer diagnosis. I acknowledge that Gabriella’s Smile Foundation will pursue and is entitled to restitution for a grant if it is determined that the information submitted on this application is false.
Heard About Us
I heard about Gabriella’s Smile Foundation through the following
I heard about Gabriella’s Smile Foundation through the following other method:

Alternatively, download the application and deliver manually to your medical provider by clicking here. Once complete, your healthcare provider must submit the application via email or fax.