Home Builders with Hearts Beneficiary Application

First Name *

Last Name *

Email *

Phone *

First Name *

Last Name *

Street Address

City, State Zip Code

Email

Phone

Description of Need *

The Board meets the Third Thursday of the month and applications are reviewed at that time.  Please provide explanation if more urgency should be considered.

How much funding are you requesting? *

How dire is the recipient's financial situation? *

Enter required value Not Significant Moderate Significant Very Significant

The urgency of the medical need. *

Enter required value Not Urgent Somewhat Urgent Urgent Very Urgent

The expected impact of receiving the funds? *

Enter required value Not Significant Moderate Significant Very Significant

The seriousness of the medical condition requiring assistance. *

Enter required value Not Significant Moderate Significant Very Significant

Has the recipient been an active member or contributor to the HBIA or Home Builders with Hearts? *

Enter required value Yes No Unknown

Does the beneficiary consent to having name, picture and need used for marketing purposes? *

Enter required value Yes No

Has the recipient previously received HBWH funds? *

Enter required value Yes No Unknown

Is the recipient a front-line worker in the building industry? *

Enter required value Yes No

Is the beneficiary sponsored by a member of the HBIA? *

Enter required value Yes No

Does the beneficiary need administrative or planning assistance to prepare for a fundraiser/event? *

Enter required value Yes No Unknown

Any additional information.