Financial Gift Application — Garage 10 Rare Disease Nonprofit

Apply for our financial gift program!

Do you or someone you know suffer from a rare disease? Garage 10 could be the assistance you are looking for. To be considered, one must be diagnosed with a rare disease and travel outside of their hometown for treatments. If applicable, please fill out the form below!

Name of Patient

First Name

Last Name

Physical Address of Patient

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Patient's Actual Diagnosis

Brief Description of Treatment

Name of Treatment Facility

City and State of Treatment Facility

Name of Person Applying

First Name

Last Name

Relationship to the Patient

Your Email

Your Phone Number

(###)

###

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Name to be Presented on Check

Address for Mailing Check

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

How did you hear about Garage 10?