Bubble Mask Application

To apply for a bubble mask for your child, please fill out our online application below.

Parent/Guardian *
Parent/Guardian
Mailing Address
Mailing Address
Date of Diagnosis *
Date of Diagnosis
(If applicable.)
Please give us a brief summary of why you think the bubble mask would be beneficial to your child.
Agreement *
We do ask that if for some reason the mask does not work for your child and you do not end up using it that you please return it to us so that it can be used to help another child. If you agree to the above statement, please confirm below to complete this application.