R4K Individual Referral Form

Do you know a child in Park County or Big Horn County in Wyoming that could use some financial assistance? We help children who are: victims of abuse, neglect, or abandonment, have either a temporary or ongoing medical condition that requires money beyond what the primary guardian is able to provide, wish to participate in school and community programs and do not have the funds to do so, and/or seek funding for advancement in an academic or social program. We will also provide funds to youth organizations when those funds will be used to directly benefit youth in the program.

The following information is being provided to help give you, the referring person/agency, guidelines that are used by the REALTORS® for Kids organization for handling the disbursement of funds to children. It is the desire of the Referral Request Committee to receive as much information about the child as possible; therefore, we ask that you tell the child’s story; and the financial circumstances. This gives the committee the opportunity to become familiar with the child’s situation and to better make the decision about approving the funds requested. Submit your referral to our board, and someone will be in touch with you soon.

Your Name*

First NameLast Name

Your E-mail*

example@example.com

Your Phone Number*

Area CodePhone Number

Guidelines:

The child must be a legal Wyoming resident and live in the Big Horn Basin area.
Age: 18 and under.

REALTORS® For Kids approves funds for the following but are not limited to:

Community-based organizations that provide suuport and on-site care for children that are: abused, neglected, abandoned, disabled or disadvantaged.
Kids with medical needs, especially those who require immediate and ongoing treatment. Insurance companies do not usually pay for the travel expenses of getting a child to and from treatment and REALTORS® For Kids will help with those expenses.
Community and school related activies, which is driven by the financial hardship of the family and child. REALTORS® For Kids will approve funds for kids who need glasses, soccer shoes, a bank instrument, project materials, participation in a sports camp, scout camp or debate trip or school function, or school related/peer activities, etc.

Child's Full Name*

First NameLast Name

Child's Residing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Child's Date of Birth*

Does the child have insurance (if applicable)*

YesNoNot Applicable

Have funds ever been requested on behalf of this child from REALTORS® For Kids before?*

YesNoUnsure

Funding Category*

Explain need

Child's Story*

Give us some details about why you believe this child would benefit from this request. Give us as many details as possible

How much are you requesting*

How did you hear about us?*

What is the name of the REALTOR® who referred you?

Today's Date*

Northwest WY REALTORS® For Kids Referral

Individual Referral Information