Request Help Form
Hi there. This is a form to request help from the Buckle Bunnies Fund. Please fill out the information below and someone will contact you as soon as possible.
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1. First name
2. Pronouns (she/her/ella, he/him/el, they/them/elle, etc.)
3. Phone number
4. Best time for a call
Please provide us with more information regarding your situation below.
6. Did you receive an ultrasound to confirm the pregnancy?
Yes, I did an ultrasound.
No, I cannot do an ultrasound but I did a pregnancy test.
No, I cannot do an ultrasound or a pregnancy test.
7. Do you know how long you've been pregnant?
8a. If you answered yes to question 7, how far along are you?
8b. If you answered no to question 7, when was your last period?
9. How do you feel about your decision?
I'm comfortable with it.
I am troubled and would like more information or someone to talk to.
Due to a recent surge in funding requests, we may be unable to cover the full cost of every procedure. Are you able to cover any portion of the procedure cost yourself, or would doing so affect your ability to pay other necessary expenses (rent, bills, childcare, food, etc)?
No but, I can pay a partial amount that can be discussed/ determined based on situation
No I cannot pay any amount
10. Anything else we should know?
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