LH Nomination Form

Storyteller nomination form

Welcome to Love Heals, we are so glad you're here! Thank you for trusting us enough to reach out. Our team will be following up with you soon. Please allow 7 to 10 days for a response.
if you are you completing this application on behalf of someone else, please write your name or company name below and phone number/email:*

Self nominations are accepted as well*
Advocate's Name

First NameLast Name
Advocate's Email
example@example.com
Advocate's Phone Number
Please enter a valid phone number.
Nominee's Name*

First NameLast Name
Nominee's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Nominee's Email*
example@example.com
Nominee's Phone Number*
What type of hardship are you experiencing?*

MedicalFamily/Foster CareProperty DamageMental HealthOther
Please let us know other ways we might be able to support

MealsTransportationYard WorkSchool SuppliesOther
Do you have a specific financial need? If so, please detail the need & cost. *
Are you willing to share your story on stage during a benefit concert or have your story shared through proxy?*

YesNo
Please Explain Your Hardship [400 words or less]*
File Upload

ONLY TO BE SUBMITTED BY SELF NOMINATIONS Please upload relevant documentation [i.e. progress note, court documentation, etc]. This helps our verification process for determining financial assistance.
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Signature

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ONLY TO BE SIGNED BY SELF NOMINATIONS *your signature indicates Love Heals permission to take photographs or videos that may contain your likeness, as well as the likeness or image of your property (the “photographs”); as well as the right to take, record, publish or obtain testimonials or other statements from me*
Signing Date

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Date
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Storyteller nomination form

if you are you completing this application on behalf of someone else, please write your name or company name below and phone number/email:*