INFORMATION OF APPLICANT:

Your Name

Date

Address

Phone number

Your Email

INFORMATION OF NOMINEE:

Name(s)

Address

Phone number

Relationship to nominee

Names and ages of the children they are caring for and
their relationship with the children

BIOLOGICAL MOTHER:

Name

Is the mother living or deceased? (If deceased, please list DOD)

If living, is the mother actively involved in the child’s life?

If actively involved, where is the mother employed?

BIOLOGICAL FATHER:

Name

Is the father living or deceased? (If deceased, please list DOD)

If living, is the father actively involved in the child’s life?

If actively involved, where is the father employed?

PLEASE SELECT ONE OF THE FOLLOWING TYPES OF SUPPORT
THAT YOU FEEL THIS FAMILY WOULD MOST BENEFIT FROM
—Please choose an option—CHRISTMAS FAMILY FUNDINGTUITION SUPPORTPAY A BILLREGISTRATION FOR ATHLETICSFOOD DRIVEOTHER (PLEASE DESCRIBE BELOW)

IF OTHER, PLEASE EXPLAIN

REFERENCES
(Please list two or three references that know
the nominee and are familiar with their situation)

Name and relationship

Phone number

Name and relationship

Phone number

Name and relationship

Phone number

IN YOUR OWN WORDS, PLEASE EXPLAIN BELOW HOW AND WHY THIS FAMILY WOULD BENEFIT FROM THE SUPPORT OF THE PINK ELEPHANT MOVEMENT