Storyteller nomination form
Hey! Welcome to Love Heals, we are so glad you're here! As you might already know, Love Heals exists to build a world where no one walks through hardship alone by connecting community, coordinating care, and covering costs for individuals going through hard things. Our primary way of covering costs is through our benefit events and campaigns where 100% of every dollar raised goes directly to our Storytellers. If you are not able to share personally, we do allow for a proxy to share on your behalf. If you are not comfortable having your story shared publicly, please let us know so we can best walk alongside you. 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 Name
Last Name
Advocate's Email
example@example.com
Advocate's Phone Number
Please enter a valid phone number.
Nominee's Name
*
First Name
Last Name
Nominee's Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
Nominee's Email
*
example@example.com
Nominee's Phone Number
*
What type of hardship are you experiencing?
*
Medical
Family/Foster Care
Property Damage
Mental Health
Other
Please let us know other ways we might be able to support
Meals
Transportation
Yard Work
School Supplies
Other
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?
*
Yes
No
Please Explain Your Hardship [400 words or less]
*
File Upload
Browse Files
Drag and drop files here
Choose a file
Please upload relevant documentation [i.e. progress note, court documentation, etc]. This helps our verification process for determining financial assistance.
Cancel
of
Signature
[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
-
Month
-
Day
Year
Date
submit!
submit!
Should be Empty: