Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Patient Name

First Name

Last Name

Patient Date of Birth

YYYY

Date of Diagnosis

YYYY

Message

Grants will be awarded for qualifying applicants in need of assistance. The distribution of funds is based on necessity and urgency of need. Grants may be used for equipment, medical costs, respite care and other associated costs directly related to an Acute Flaccid Myelitis diagnosis. Please be specific in explaining the need for a grant. A written medical diagnosis, vendor bills and other documentation will be requested at the time of the award.

Aflredo’s Magic Wand: A Children’s Book About Acute Flaccid Myelitis

By Rachel Scott

Available now at Amazon.com