APPLICATION FORM CLICK HERE TO DOWNLOAD A PDF APPLICATION FORM Right-click and “save as” to your desktop Fill out and email to: email@example.com *Please complete all information, otherwise your request may be delayed Date PERSON NEEDING ASSISTANCE Name (required) Date of Birth (required) Diagnosis (required) Address (required) Your Email Phone PERSON MAKING REQUEST Name (required) Date of Birth (required) Diagnosis (required) Address (required) Your Email (required) Phone (required) REQUEST STATEMENT List the type of assistance you are requesting, along with costs. Please be specific with your request. Also include attending doctor's name, address and phone number. Statement EXTRA INFORMATION 1. How many people live with the applicant? 2. Yearly family income (You may be asked to provide copies of pay stubbs, W-2s, and so on.) 3. Have you ever received assistance from any non-profit organization? 4. How did you hear about The Gracie Pridmore Foundation? FOR HBOT APPLICANTS ONLY 1. Has the applicant ever received HBOT? Yes or No If Yes, please list how many treatments and where they were received. 2. Would you be willing to shoot before and after HBOT videos of the applicant to be used on The Gracie Pridmore Foundation website? Yes or No To the best of my knowledge, the above information is truthful and accurate. Name of Applicant (required) Date Name of Guardian (required) Date QUESTIONS? Feel free to contact us with any questions you may have by using the Contact Form on the previous page. We look forward to hearing from you! Are you a person or a spambot? Please use 'Captcha' and hit send.