Your email *

Name (First & Last) *

If applicant is under 18, name of parent/guardian

Street Address 1 *

Street Address 2 (if applicable)

City, State

Postal Code

County *

Phone number

Applicant's date of birth *

Amount Requested (Up to $2,000) *

Receipts

Qualified recipients must be able to provide receipts of provider services, treatments, supplements or other wellness intervention. If selected, applicant will be awarded up to $2k to reimburse out of pocket expenses.

Reason for Request: Include as much information as possible to help us consider all aspects of your situation and need. *

Do you (applicant) or your family have a relationship with anyone on the Sam's Spoons Foundation Board? *—Please choose an option—YesNoNot sure

If yes, please explain the relationship

Permission to use Name/Photo on SSF website, social media and, if possible, to accept the check in person on a designated day. If YES, please email photo to info@samssppoons.org by the application deadline.

YES, I give permission to use my name and photo (or loved ones name if completing application on their behalf)
NO, I do NOT give permission to use my name or photo