Promise Application
The mission of Gracie's Promise is to raise funds and give financial assistance to families with members, primarily children 21 years of age or younger, battling catastrophic medical circumstances. These families will be selected from applications submitted to the Board of Gracie's Promise.

Before an application may be considered for financial assistance, Gracie’s Promise requires the following three things:
1. The application must be submitted by the ill/injured child’s custodial parent or legal guardian. The custodial parent or guardian may complete an application on-line or download application here.
2. The applicant family must either designate a sponsor, preferably not a close family member, or request Gracie’s Promise to appoint a sponsor for the family. The sponsor will be required to provide written quarterly updates to Gracie’s Promise about the current status of the child and family. For a designated sponsor, please include all contact information. Download sponsor letter here.
3. The ill/injured child’s treating physician must submit a letter written on stationary bearing the doctor’s letterhead or complete a physician's report form to confirm the child’s diagnose, course of treatment, prognosis, and the family’s need for financial assistance. The letter/form must be sent to Gracie’s Promise directly from the doctor’s office and may not be submitted by the applicant family. Download physician's letter here.

After the timely submission of all required information, the documents will be reviewed by the Application Assessment Committee to determine if the applicant family qualifies for financial assistance. The Committee will then make a recommendation to the Gracie’s Promise Board of Directors to either approve or deny the family’s application. Board members meet once each month to determine how to dispose of outstanding applications. After a decision is made by the Board, the applicant will be notified by U.S. Mail of its final determination.

How quickly Gracie’s Promise receives the required information determines how soon a final decision may be made regarding financial assistance for an applicant family. Applications are pended for a period of six months from the date of confirmed receipt in order for the Committee to accumulate the necessary information. If all documentation is not received on or before that deadline, the application and any other documentation on file will be destroyed; Gracie’s Promise will not issue any notice of the destruction.

There are two options to apply:
1. Download the application by clicking the link to the right.
2. Fill out the online application below.
Online Application Form

Family Contact Information

Sponsor Information


Medical Information

Privacy


Do you verify that the information you have provided the Board of Gracie's Promise is accurate and truthful?
The Board of Gracie's Promise considers the information in this application to be private and confidential. Only the members of the Board and your sponsor will have access to your information. You may be asked to permit the Board to use either the patient's or your family's story as publicity in order to either inform the public of Gracie's Promise's activities, or to solicit additional donations in order to assist other families in the future, or both. No information will be disclosed, at any time, without prior written authorization from you. Refusal of this request will not impact the Board's decisions. The Board meets monthly and will process your application as quickly as possible. If you have any questions, please contact Dan Doherty at (307) 534-5352.
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Download Application

Please download the application, fill it out, and mail it to:

Gracie's Promise
PO Box 1366
Torrington, WY 82240

(307) 532-0144