*
Required Fields
Cystinosis Memorial Fund Application
First Name
Last Name
Address
Address 2
City
State/Province
Zip/Postal Code
Country
Email
Confirm Email
Phone
Birthdate
Are you a person living with cystinosis?
Yes
No
Total amount of funding (USD) needed
Breakdown of total amount required (please provide information on amount required to help expedite your application) Max request is $1,000 USD. Note: Proof of expenses/receipts will be requested if awarded.
Please explain why financial assistance is needed.
How will funding from the Cystinosis Memorial Fund be used?
What would it mean to you to be awarded funding from the Cystinosis Memorial Fund?
What is one thing that cystinosis has taught you?
If selected as a recipient of the Cystinosis Memorial Fund, are you willing to share photos and follow up information
Yes
No
PLEASE NOTE:
Recipients of the CMF will be required to submit receipts for programming and services rendered. All applications will be reviewed within 4-6 weeks of submission. A CMF committee will determine awardees and notices will be sent out quarterly. CRN will be responsible for the distribution of funds (up to $1,000 USD per awardee) based on the need specified in this application. For questions, email
[email protected]
or
[email protected]
By checking this box I am attesting to the fact that I have a financial need for this award. I agree to use any monies received from the CRN/Cystinosis Memorial Fund explicitly for the purposes submitted in this form. If receipts are requested after the goods and services are booked or complete, I agree to produce them within 90 days.
Submit
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