Salty Life Activity Grant Application

Provided by the Vivian Lee Foundation.

There is a maximum of 1 request for assistance per year per family.

Date Date / MM / DD YYYY
Family Information
Parent/Guardian Name #1 Parent/Guardian Name #1 First Last
Patient Name Patient Name First Last
Age
Family Address Family Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Phone #1 Phone #1 - ### - ### ####
Email #1
Medical Information
Name of Physician Treating the Patient for CF Name of Physician Treating the Patient for CF First Last
Clinic or Hospital Name:
Social Worker that can confirm CF diagnosis Social Worker that can confirm CF diagnosis First Last
Direct Phone # of Social Worker (we must have this to confirm diagnosis) Direct Phone # of Social Worker (we must have this to confirm diagnosis) - ### - ### ####
Direct Email of Social Worker (we must have this to confirm diagnosis)
Activity Information
What type of activity does your child want to participate in?
Does this activity have a specific start date?
Please provide a web link to the activity, camp or sport that your child will be participating in:
Is there anything else you would like to tell us?
Please allow 3-4 weeks for your application to be processed. Confirmation of cystic fibrosis diagnosis must be maintained by Vivian Lee Foundation prior to providing assistance money. A check will be mailed to you after confirmation has been determined by Vivian Lee Foundation.

One grant per CF patient per year of $250 will be sent to approved applicants.
Signature and Acknowledgment
By submitting this application, I hereby authorize the Vivian Lee Foundation to obtain my protected health information. This medical authorization hereby authorizes your medical provider to speak with Vivian Lee Foundation and have access to all your medical records on your child. The authorization is obtained for this transaction only. The authorization expires when this transaction is complete.

I verify that the information provided in this application is complete and accurate. I also understand the Vivian Lee Foundation reserves the right at any time and without notice to modify the assistance and discontinue any or all of the programs and related eligibility criteria at any time.
Draw your signature into the box below.

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.

Salty Life Activity Grant Application

Salty Life Activity Grant Application

Family Information

Medical Information

Activity Information

Signature and Acknowledgment