Online Application — The Rorie Mae Foundation

Online Application.

To apply for financial assistance, please fill out this brief application. We will email you back as soon as possible.

Name of Parent or Contact

First Name

Last Name

Phone

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Name of Child (If Applicable)

Type of Assistance Requested

Choose one or both

Funeral Expenses

Counseling Expenses

Story

We want to hear your full story when you are ready to share, but for the purpose of this application, please give us a brief summary of your story.

Other Comments/Questions