Apply (Copy) — Rayan's Crayons

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SMILING STEPS: APPLICATION PROCESS FOR RAYAN’S CRAYONS

Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone Number

(required)

Date of Birth

YYYY

Household Composition

(# of family members, dependents)

Employment Status

Average Household Gross Income

Are you willing to provide supporting documentation such as proof of income, identification documentation, medical records, etc?

Specify type of assistance being sought:

(We would love to hear your child's story and understand the specific way you would like to gift them a smile")

Do you consent collect, store, and process the personal information you just provided for the purpose of assessing elgibility and providing assistance?

(Your information will be handled with compliance to data protection laws - see Privacy Statement)

Child Name

First Name

Last Name

Child's Birthdate

YYYY