Getting Started

Below is an application form which you need to fill out in order to start the process. Our medical advisory board will review your application and you will hear from us within a week as to whether we will be able to help you.

Criteria for getting into our program:

1. You must have a potentially life-threatening illness.

2. You must be the parent of a child 21 years or younger, or you are the primary caregiver of that child.

3.  First responders only need to have a life-threatening illness to qualify for our free service.

If you do not meet our criteria and are interested in making a video, please email us at and we can refer you to some people who might be able to help you.

The Process

Intake Form