Transplant Grant Application

Transplant Grant Application
Cystic Fibrosis Patient Name*

First NameLast Name
Patient Date of Birth*

MonthDayYear
Date
Which best describes you in relation to the CF patient?*

Self/CF PatientParentGrandparentLegal GuardianOther
Primary Caretaker Name*

First NameLast Name
Mobile Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email*
example@example.com
Patient's Primary Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Transplant Center Name*
Transplant Type*
Tell us about your CF Care Center
Care Center Name*
City, State*
Coordinator/Social Worker *
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Fight CF Foundation requires verification of the patient's CF diagnosis from your CF Care Center. Please obtain a letter from your CF Care Center with the patient's name, date of birth, and verification of thier diagnosis.

Verification letter can be emailed to grants@fightcf.com or text to (757) 705-0014
How were you referred to us?*

Social WorkerDoctorFamily/FriendCompassOther
Has anyone else applied for this grant on behalf of this CF patient?*

YesNo
Please read carefully and sign below
Fight CF Foundation transplant grants are awarded on a case by case basis per transplant, per cystic fibrosis patient based on application approval and available funding.

Fight CF Foundation transplant grants are available to anyone with cystic fibrosis who receives care at Children's Hospital of The King's Daughters in Norfolk, VA or Naval Medical Center in Portsmouth, VA.

All grant funds are made available through our partnership with Children's Organ Transplant Association (COTA). Grant awardees will need to establish an account with COTA. Once a COTA account is established and verified, Fight CF Foundation will fund the account with the full grant amount within 5 business days.

I hereby certify that, to the best of my knowledge, I understand the above qualifications and conditions, and that all of the information provided is true and accurate. Any mirespresentation of information provided will nullify this application.
Signature*
Should be Empty:

Transplant Grant Application

Tell us about your CF Care Center

Please read carefully and sign below