Request Funding

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Today's Date*

Child's Name*

Child's Address*

Diagnosis/Diagnoses*

Parent/Gaurdian Name*

Parent/Guardian Email*

Parent/Guardian Phone*

Amount Requested*

Tell us why you are requesting funding.*

Other resources you have attempted or exhausted:*

410-352-5011

P.O. Box 1322

Ocean Pines, MD 21811

Name*

Email*

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