Food & Fuel Fund Application - Project Sweet Peas

ID Verification and Documentation
***PLEASE READ BELOW CAREFULLY TO SUBMIT CORRECTLY OR APPLICATION WILL BE DENIED:

In order to verify this application, a Photo ID picture MUST be taken WITH or NEXT TO your NICU infant(s). It can block the face or any identifying features, and WILL NOT be used for any publications of any kind; it is strictly for verification purposes.

If for any reason this is not possible, the only other accepted format would be with the Photo ID pictured next to the hospital business card with the date of application submission clearly printed on it.

Photo ID must be clear, legible, and in focus.

***There are no exceptions to this requirement - if this is not provided as requested, this application will be denied.***
Driver's License or State Photo Identification WITH NICU Infant IN THE SAME PICTURE:*

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Parent Information
Name*

First NameLast Name
Phone Number*
Please enter only numbers, including area code
Email*

Confirmation Emailexample@example.com
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Grant Funds Receipt Preference

There are two options to receive funds - Visa Gift Card mailed to physical address, or Non-Business PayPal account via email. Please indicate your choice below and ensure the mailing address or email address is entered correctly, as funds cannot be reissued.
If selected, will you use funds for expenses related your child's hospitalization, including food and transportation expenses?*

YesNo
If selected, how would you prefer to receive the funds? **

PayPalVisa gift card
Personal PayPal (No Business Accounts)
example@example.com
Mailing address same as above?

YesNo
Mailing Address for Gift Card

Street Address

Street Address Line 2

CityState

Zip Code

Media Consent

Your consent below is greatly appreciated, as it will allow us to use photographs and interviews for this program. Photographs and interviews may be used by Project Sweet peas to tell the stories of participants of the NICU Family Assistance program. Photographs may be used for informational, soliciting donations, press and/or marketing materials.
I give consent to have my/my child's photographs and interview quotes to be used.*

YesNo
Please upload a picture of your child(ren) here:

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Please provide quote below with how the Food & Fuel Assistance grant would benefit your family.

Acknowledgement of Terms
I have read and understand Project Sweet Peas’ guidelines. By signing below, I agree that that the information on this form is true and correct to the best of my knowledge. I attest that any financial funding if awarded will be utilized for the expenses listed above. I release Project Sweet Peas’ responsibility for fund allocation after funds distribution. I understand that all applications will be reviewed individually and that I am not guaranteed funding based upon submission of my application.

Clear
Typed Name*
Should be Empty:

Food & Fuel Parent Application

ID Verification and Documentation

Parent Information

Grant Funds Receipt Preference

Media Consent

Acknowledgement of Terms