Grant Application Worksheet

Donate TodayMake a Donation

Please prepare the required attachments* before starting your application. Once you begin the online application, you will NOT be able to save and come back to it.

*The required documents are proof of diagnosis, signed by physician, and personal essay explaining financial hardship and how the funds will be used if rewarded.

    Parent/Legal Guardian Information

    First Name*

    Last Name*

    Address*

    City*

    State*

    ZIP*

    Home Phone*

    Cell Phone*

    Email* (This will be the primary means for communication from/to ACD. Please make sure this email is one that is checked frequently)

    Patient's Information

    First Name*

    Last Name*

    Address*

    City*

    State*

    ZIP*

    Is the child 16 years old or younger? Enter Yes or No* (Child must be 16 or younger to be eligible)

    Medical Information

    What is the CCDS diagnosis of the Child? (ie AGAT, CTD, GAMT)*

    Doctor Information

    CCDS Doctor's First Name*

    CCDS Doctor's Last Name*

    Doctor's Specialty (ie. genetics, neurology)*

    City*

    State*

    Phone*

    Name of Clinic or Facility*

    Required Attachments

    Proof of CCDS diagnosis

    Financial Hardship Essay

    For your security, please type the words that appear below into the entry box.
    captcha

    Entry Box

    **If the child is under 13, the parent or legal guardian must complete this form. Personal information and health information is being disclosed. ACD may use the materials submitted for the purpose of determining the distribution of the PatientStrong grant. The ACD is not obligated to make any awards for any grant cycle. The ACD may determine in its sole discretion not to make any awards for one or more grant cycles and may determine to terminate the grant program at any time without obligation to any applicant.

    Search Our Website

    Patients and Families

    Clinicians

    Research

    About