Brady's Buddies
Application Form
Legal Name
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First Name
Last Name
Phone Number
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Area Code
Phone Number
Date of Birth
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Month
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Day
Year
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How did you hear about us?
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Best Time to Call
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E-mail
*
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Please select one of the following:
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I am the family in need
I am related, but not the family in need
I am applying on behalf of a family in need and they are aware
I am applying on behalf of a family in need but they are not aware
The family in need lives in central Indiana:
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Yes
No
The family in need is the legal guardian of a patient admitted or recently admitted to a pediatric intensive care unit:
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Yes
No
If yes, at which children's hospital?
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Riley Children's Hospital
Peyton Manning Children's Hospital
Other
Without including private patient information, please provide details of the family in need and how we can help:
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Please type N/A if choosing to upload a written file.
If you prefer to upload a file, please do so here:
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I hereby authorize The Brady Foundation to verify all information contained in this application. I authorize those who are contacted to disclose any and all information to The Brady Foundation. I release all such persons or entities from liability that may result or arise from The Brady Foundation’s collections of all such evaluations or information for its consideration of my application. Should my application be accepted, I agree to follow the policies of The Brady Foundation and to refrain from inappropriate behavior in the performance of my services on behalf of the foundation. I understand that this personal information will be held confidential by the foundation staff.
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I agree with the statement above
I disagree with the statement above
I am the parent/legal guardian of the applicant and I agree with the statement above
I am the parent/legal guardian of the applicant and I disagree with the statement above
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