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What Happened To Anitra?

SECTION 1: APPLICANT INFORMATION

Parent/Guardian Full Name:

Relationship to Participant:

Parent

Grandparent

Legal Guardian

Foster Parent

Other

Phone Number *

Email Address *

Address

Street Address

City

State

Country

Enter your country

Postal Code

SECTION 2: PARTICIPANT INFORMATION

Participant Name:

Date of birth

School Name (if applicable):

Grade Level (if applicable):

Is the participant:

Child/Youth (Ages 5–17)

Young Adult (Ages 18–25)

If applying for more than one child, please list additional names and ages:

SECTION 3: FAMILY SITUATION

Has the participant experienced the loss of a parent or primary caregiver?

Yes

Name of Parent/Caregiver:

Relationship to Participant:

Date of Loss:

Cause of Loss:

Gun Violence

Illness

Accident

Incarceration

Domestic Violence

Other

Please briefly describe your family's current situation and needs:

SECTION 4: SERVICES REQUESTED

Which services are you interested in? (Check all that apply)

Grief Support Resources

Counseling Referrals

Mentorship Program

Academic Support

Tutoring Referrals

Leadership Development

Life Skills Training

School Supplies

Clothing Assistance

Hygiene Products

Holiday Assistance

Financial Literacy

Career Readiness Support

Transportation Resource Referrals

Housing Resource Referrals

Community Resource Referrals

SECTION 5: CONSENT & SIGNATURE

I certify that the information provided is true and accurate to the best of my knowledge. I understand that submission of this application does not guarantee services and that eligibility is based on program requirements and available resources.

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Full Name

Phone *

Email *

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