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Financial Assistance

First and Last Name:

Name of Patient:

Phone Number:

Home Address:

Email:

Relationship to Patient:

Pompe Diagnosis

Physician:

Wha type of financial assistance do you need?

Duke Pediatric Pompe Conference

Duke Scholarship

Medical Equipment

Travel to Appointments (Gas/ Accommodations)

Other (describe below)

In a few sentences, describe the type of assistance you are requesting:

We make every effort to accommodate as many requests as possible and will be in touch after reviewing your form.

Grant's Giants is an all volunteer 501(c)(3) non-profit organization.

All contributions to Grant's Giants are tax deductible to the extent permitted by law.

Tax ID : 92-1236152

© 2024 Grant's Giants

Grant's Giants is an equal opportunity organization and will not allow discrimination based upon age, ethnicity, ancestry, gender, national origin, disability, race, size, religion, sexual orientation, socioeconomic background, or any other status prohibited by applicable law.

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