Rising Stars Fund Application Date *Personal InformationName *Relationship to Child *Street Address *Apartment, suite, etcCityStateZIP / Postal CodeEmail Address *Phone *Child InformationBirth Date of Child *Name of Child *Diagnosis of Child *Requested ItemItem Name *Detailed Description *Link to Item (optional but extremely helpful)Paste Link to ItemColor (optional)Size (optional)Model (optional)Brand / Manufacturer (optional)Current ServicesServices or benefits you currently receive for your child: *Social SecurityEaster SealsIDD ServicesOregon Health Plan (OHP)Group or individual health insuranceNone of TheseConsentConsent *Confirm that the information provided is true and accurate.ApplyPlease do not fill in this field.
