TLP404 Family Nominations

Today's Date:*

MonthDayYear
Date
The Nominator *

First NameLast Name
Address:*
Nominator Info
Phone Number:*
Nominator Infor
Email:*
Nominator Info
The Nominee*

First NameLast Name
The Nominee (2)

First NameLast Name
Age:
Nominee Info
Race:
Nominee Info
Gender:
Nominee Info
Email:*
Nominee Info
PHONE NUMBER:*
Nominee info
ADDRESS:*
Nominee Clothing Size
Tops*

XSSMLXL2XL3XL4XLOther
Bottoms*

XSSMLXL2XL3XL4XLOther
Number of Children*

Nominee's Children*

	Age	Gender	Shirt Size	Pant Size
Child 1
Child 2
Child 3
Child 4
Child 5
Child 6
Child 7

Nominee's Needs Assessment*

	Y	N	N/A	Notes
Are you/they in school?
Do you/they need education assistance?
Do you/they need help with parenting classes or resources?
Do you/they have a cell phone?
Do you/they need help finding stable housing?
Are you/they employed?
Do you/they need help finding stable employment?
Do you/they need any substance abuse treatment?
Do you/they need any behavioral health treatment?
if you are selected for our initiative, do you consent to being photographed and/or filmed for the The Love Project 404 marketing purposes?

Family Sponsorship Initiative

Known Monthly Expenses*

	$
Rent/Mortgage
Power/Gas
Water
Internet
Medical Expense
Other
Other
Other
Other
Other

Please describe any expenses above labeled "Other"
Please tell us why you nominated this family and identify what you believe is the nominee's most pressing critical needs.*
Should be Empty: