Identification
Please complete all required fields and provide as much detail as possible in the comment fields.
Name of the sick child*
Date of birth of the sick child*
The child is *
Name of the person making the request*
Family connection
Phone number
Applicant's relationship with the sick child*
Name and title of the person who referred you to our services*
If no one referred you, enter NONE
Number of children aged 0-17 in the family - including the sick child * 
1/7
Parent 1 Information
Parent 1 is*
Parent Name 1*
Parent 1 is*
*Only parents who are Canadian citizens or permanent residents are eligible for our assistance program. Do not complete this form if you do not meet this criteria.
Parent 1's date of birth*
Marital status*
Housing*
Address*
Only New Brunswick residents are eligible for our assistance program. Please do not complete this form if you do not meet this requirement. 
Parent 1 Cell Phone*
Parent 1 Email*
2/7
Parent 2 Information
Parent 2 is
Parent 2 Name
Parent 2 is
*Only parents who are Canadian citizens or permanent residents are eligible for our assistance program. Please do not complete this form if you do not meet this requirement.
Date of birth of Parent 2
Marital status
Housing
Address
*Seuls les résidents du Nouveau-Brunswick sont admissibles à notre programme d'aide. Ne remplissez pas ce formulaire si vous ne répondez pas à ce critère. 
Parent 2 Cell Phone
Parent 2 Email
3/7
Sick child
Diagnosis type:
Date of diagnosis*
Name of the attending physician*
Hospital*
Date of the most recent medical exam*
Expected end date of treatment*
The child has been hospitalized for an indefinite period. *
Physician's letter*
Please attach a letter from your primary care physician confirming the diagnosis and treatment provided.  
Background*
Requested amount*
If you are purchasing a piece of equipment or any type of device, please specify.
4/7
Social media and fundraising campaigns
Community
Please check all that apply.
Amount raised to date*
Comments
5/7
Supporting information
We need to assess the impact of the illness on your income in order to determine the amount of financial assistance that is eligible.
Proof of citizenship * 
Additional comments 
6/7
Final steps
Pictures of the child *
Please provide one or more good quality photos of the child. The photos could be used to promote our mission.
By checking this box, I agree to the above points and confirm that the information provided is accurate and the attached documents are true. *
Please check the required fields.
7/7
Next
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Supporting young people and their families facing illness or major health problems.
The Michel and Yolande Bastarache Foundation is a registered charity (CRA): 731347027RR0001
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