APPLY NOW (DRAFT) | Leilani's Hope

Applicant First Name

Applicant Last Name

Applicant City of Residence

Applicants must reside within the Region of Waterloo to be eligible for support

Applicant Phone Number

Applicant Email

Applicant Date of Birth

Year

Month

Day

Are you applying as an individual or as a family?

Individual

Family

Please list the name, relationship, and age of any other family members in need of support.

Briefly explain why you need the support that Leilani's Hope provides

Known medical diagnosis or conditions, if any

Other determining factors

Please share any extenuating circumstances that you feel are important for us to consider when evaluating your request for support.

What is your annual household income before taxes from all sources?

I have extended health care benefits

Name of referring party

Referral is not required

Contact info of referring party

Please ensure your reference is aware that you have applied for support through Leilani's Hope and that you have listed them as a reference.

We are asking the following demographic questions to gain a better understanding of our applicants. Please note that answering these questions is completely voluntary, and you are not required to do so. Your responses will be kept confidential and will only be reviewed for the purposes of application evaluation.

What is your current relationship status?

Do you identify as a member of any of the following groups?

Check all that apply

CERTIFICATION: By submitting this form, I hereby certify that, to the best of my knowledge, the provided information is true and accurate

Application for Support