404:LTR - Tattoo Removal Assistance Application

404:LTR Community Outreach

Tattoo Removal Assistance Application
Thank you for your interest in our tattoo removal assistance program. Our mission is to provide free or reduced-cost tattoo removal for individuals who want to remove tattoos connected to difficult pasts, such as those related to trafficking, ownership, gang involvement, racist affiliations, or incarceration.

We strive to make this service accessible and affordable. While we aim to cover costs for those who need it, any contribution you are able to make helps us continue offering free or reduced-cost removals for others in similar situations. Every bit helps to ensure that more people receive the support they need.

Your responses are confidential and will help us assess eligibility and ensure this program is the right fit for you.
1. Personal Information
Name*

First NameLast Name
Birth Date*

MonthDayYear
Date
Age*
Email*
example@example.com
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

3. Meaning and Background of the Tattoo
1. Describe the Tattoo’s Background and Purpose: Please explain, why you got the tattoo, its original meaning, and any specific connections to past experiences, relationships, or affiliations (such as property marking, gang involvement, racial hate group symbols, or prison affiliations). *
2. Current Feelings and Reason for Removal: Why do you want this tattoo removed? How will removal impact your life?*

4. Tattoo Images
Photo Upload*

- Please provide clear, well-lit photos of the tattoo. Multiple angles may be helpful if possible. Ensure the tattoo is fully visible in the photo.
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5. Lifestyle and Current Involvement
1. Describe Any Lifestyle Changes: In what ways have you distanced yourself from any past affiliations, environments, or harmful relationships? Include any steps you’ve taken (e.g., leaving a gang, disassociating from racist groups, or escaping trafficking).*
2. Programs or Support Involvement (optional):
Please share any community groups, support systems, or positive activities you are currently engaged in, if applicable.

6. Motivation and Goals for Tattoo Removal
1. How Will Tattoo Removal Help You?*
Describe how you believe removal will benefit your life, such as aiding in employment, helping with relationships, building self-esteem, or reintegrating into the community.
2. Future Goals and Aspirations:*
Feel free to share any personal or professional goals you are working toward and how tattoo removal fits into these goals.

7. Consent and Confidentiality
Yes, I agree to the terms and understand that my information will be kept confidential.
Yes, I acknowledge and understand the removal process.

8. Additional Support Needs
Our program aims to support not only tattoo removal but also your overall well-being. If you’re interested, we can help connect you with organizations that offer counseling or other types of support.
Yes, I would like assistance finding support services.No, I do not need additional support services at this time.
Counseling: (e.g., trauma recovery, mental health support, addiction counseling)Career Assistance: (e.g., job training, resume building, interview preparation)Educational Support: (e.g., GED programs, vocational training, college counseling)Legal Support: (e.g., assistance with criminal records, family law support)Housing AssistanceOther
Thank you for completing this application. We will review your information and reach out soon regarding the next steps. Please contact us with any questions or concerns about this process at.:

Text: 208.534.6449

Email: 404communityoutreach@gmail.com
Signature*

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404:LTR Community Outreach