Share the ! Nominate Someone Looking for a printable form? Click here. Make a Nomination Name YOUR INFORMATION (The person completing this form) First Name * Last Name * Phone Number * Email Address * Address * City * State * Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana IAIowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip Code * Referring Person(s) * Please list the board member, advisory committee member or referral partner that you know/are affiliated with (If you don't have one, please contact us directly) RECIPIENT INFORMATION (Person/family you are nominating) Name(s) * Phone Number * Address * Recipient City * Recipient State * Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana IAIowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Recipient Zip Code * Recipient Email * Background & Hardship Information * Please share a brief description of the recipient’s background, including the unexpected event that they’ve encountered Funding Request * What is the total amount of money that you are requesting for the recipient? How will covering these expenses benefit the recipient? * How will this money be used? * Please give a detailed explanation of specific costs. How do you know the recipient? How has this recipient been vetted? * Has the recipient received funding from The River Ellis Foundation before? * Yes No Is the recipient currently receiving financial support from any other organizations? If so, please list the sources of funding as well as how long the recipient has been receiving this financial assistance. * Please check any boxes that apply to the recipient(s) Loss of employment Unexpected Illness/Injury Change in family dynamics (divorce, separation) Death of immediate family member Not insured Other Does the recipient agree to ‘Give a Sunrise’ to someone else in the community someday in the future? * Yes No Will the recipient agree to sign a media release form so that their story can be shared? * Yes No Once this form has been submitted, the request will be reviewed. A member of the foundation will notify you of the status of your request as soon as the review is completed. Your Full Legal Name * I certify that the information submitted in this nomination form is true and accurate to the best of my knowledge. * I Agree recaptcha * Thank you for helping Give A Sunrise! #GiveASunrise Subscribe to our newsletter Name First Email CAPTCHA Δ
