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L4L Fundraiser Page
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Application
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Parent's Lymphedema Road Map
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Links
LE Treatment Videos
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DONATE
Home
About
Our Story
Mission/Vision
Board of Directors
Contact Us
Events
Links For Lymphedema
L4L Fundraiser Page
Camp Watchme
Support A Warrior Day
Shop
Apply
Application
Resources
Parent's Lymphedema Road Map
Treatment Guide
Links
LE Treatment Videos
BFF Blog Posts/Media
Lymphedema Facts
Pediatric Bandaging Kit Guide
BFF Brochure
Pediatric Lymphedema Alliance Brochure
DONATE
you will be contacted via EMAIl once you have completed all steps of the application process.
*If you do NOT have a lymphedema diagnosis, please do not fill out questionnaire.
Mother's Name
*
First Name
Last Name
Father's Name
First Name
Last Name
Child's Name
First Name
Last Name
Child's DOB
Child's Gender
Male
Female
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone #
(###)
###
####
Email
Mother's Occupation
Father's Occupation
Annual Household Income
Number of people living in household?
1
2
3
4
5
6
7
8
9
10
Primary Language
Do you have health insurance?
Yes
No
Explain your current financial situation and why you are requesting help.
How did you hear about Brylan's Feat Foundation?
What areas are affected by lymphedema?
What lymphedema treatment (s) are you seeking help with?
Is there a family history of lymphedema?
Does your child have any other medical conditions?
At what age did your child show signs of lymphedema and at what age was it officially diagnosed?
How were they diagnosed (ultrasound, lymphoscintigram, etc.) and by whom?
Is your child currently seeing a CLT (certified lymphdema treatment)? Have they received proper CDT (complete decongestive therapy)/ reduction phase including short stretch bandaging?
What is the current treatment plan, if any, and is it consistent?
I know that if my application is not completed (uploaded documents, questionnaire, signed responsibility form and signed photo authorization) within 3 days, my application is subject to denial. Brylan's Feat Foundation will not contact you regarding assistance until your request is submitted.
Yes, I understand
I understand that failure to comply with treatment may result in discontinuance of assistance for care.
Yes, I understand
I understand that it is my responsibility to follow up with Brylan's Feat Foundation when new treatments are needed and that proof of compliance might be requested.
Yes, I understand
Thank you!
