top of page

Application
 

Format for phone number is 10 digits only, no spaces or special characters. Example 19184567890 If you do not have a phone please provide alternate contact information.

If your physical address is different than your mailing address please include both.

Please list all items you may need assistance with .

Due you currently receive any of the following assistance (check all that apply)

*We use the LIHEAP requirements in determining applicant eligibility. (Please see our Resources page for current LIHEAP guidelines.)

If you do not have reliable transportation, please provide a detailed explanation on how the applicant will attend the activity requirements.

Will the candidate attend a minimum of 75% of functions for the duration of the activity?
Yes
No
Will you submit a photo of your child while participating in their activity?
Yes
No

Photo submission is voluntary and not required for application submittal, review or program acceptance. Note: Picture cannot include any identifying features of anyone besides you and/or your child.

May we use the photo for our website?
Yes
No

Note: In the event your photo submission contains other people, we will attempt to modify the photo to protect the privacy of individuals who have not given us permission to use their image.

May we use the photo for reports to our donors?
Yes
No

This helps us with our fundraising efforts, Thank You.

Do you plan on submitting the Adult Survey and Participant Survey at the activities conclusion?
Yes
No

Survey completion is voluntary and not required but will help us in the pursuit of more funding.

bottom of page