Apply for Support

Patient Information
Patient Name
Patient Address
Patient Phone Number
Patient Email Address
Patient Date of Birth
Date of Diagnosis
Is the patient a minor?
Are you applying on behalf of a patient or patient's parent/guardian?

Primary Caregiver Information
Primary Caregiver Name
Primary Caregiver Address
Primary Caregiver Phone Number
Primary Caregiver Email Address
Treatment Information
Is the patient currently receiving treatment?
Treating Facility
Treating Doctor
Request Payment Amounts
Payment Detail
Payment Type
Payment Amount
Payment Documentation
Payment Description
Statement of need
Has the patient received other assistance?

By checking this box, I authorize Gray Warriors to use my or my dependent’s first name, photo and story in any type of print or advertising related to the Gray Warriors mission. Note: If the applicant is not the patient or patient’s guardian, do not check this box. (Optional)

By checking this box, I understand that Gray Warriors has limited funds available and that the patient listed on this application is in need. I also understand that by receiving a donation from Gray Warriors, this patient is utilizing those limited funds and, as a result, another patient may not be able to receive funds.

I hereby authorize the release of information to Gray Warriors (GW) in order to process my application for assistance. I certify the information I have stated here is true and correct. I understand GW may verify the information on this application and that deliberate misrepresentation of information may subject me to denial of assistance and/or services. I give permission to GW to discuss this application with any others deemed necessary to verify my information. I understand that all information will remain as private as possible within these entities. GW will determine if I meet the criteria based on an internal review of the application and other supportive materials, and is not required to provide a reason for denied applications.

In addition to the above Grant requirements, if I am chosen for this Grant, I may be requested to submit a photo. I hereby grant GW the irrevocable right and permission to use photographs and/or video recordings of me on the GW website and other websites and in publications, promotional flyers, educational materials, or for any other similar purpose without compensation to me. Should that request occur, I hereby irrevocably grant GW and its licensees, assigns, successors and other parties acting with its permission the perpetual rights throughout the world to use my name (first name, first initial of last name), image, likeness and personal brain cancer/tumor story (including without limitation how this Grant will be used) in GW’s informational and promotional materials in any media. Nothing in this agreement shall obligate GW or any third party to make any use of the rights granted by me under these Terms. I hereby waive any right to inspect or approve any party’s use or exploitation of the rights granted under this agreement. I hereby release and discharge GW and its licensees, assigns, successors and other parties acting with its permission from any and all claims and demands arising out of or in connection with the exploitation of the rights granted under these Terms, including, without limitation, any and all claims for compensation, claims of defamation or any claims regarding rights of privacy or publicity. To protect my identity, GW will not use my full last name on any promotional materials.

I hereby warrant that I am eighteen (18) years of age or older and competent to contract in my own name or, if I am less than eighteen years old, that my parent or guardian has signed this release form below. This release is binding on me and my heirs, assigns and personal representatives.

I state further that I have read these Terms in their entirety prior to affixing my signature below, and that I am fully familiar with the contents of these Terms and that I will comply fully with them. These Terms shall be binding upon me and my heirs, legal representatives, and assigns. The invalidity or unenforceability of any provision of these Terms shall not affect the validity or enforceability of any other provision of these Terms.


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