Request for Support
Burlington Womenade Inc. Request for Support Form
Email address *
Today's Date: *
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Your Name: *
Your Phone Number: *
Name and location of person(s) in need of support: *
If the beneficiary does not live in Burlington, MA or surrounding towns, please describe any other connections to the area:
Please describe the circumstance that caused a crisis for this person/family. Be specific, if possible (examples: illness, injury, loss of wages, hardship, etc.): *
Type of need (examples: a bill paid- please specify amount, gift cards, meals, etc.): *
Has this person/family received support from Burlington Womenade in the past? *
Please list any other support or aid that has been received (including expected insurance coverage):
A Womenade representative will contact you within 14 days or less of this submission. This application will be kept confidential and will only be disclosed to Womenade's directors. Financial assistance is not guaranteed as grants are discretionary and based on a variety of factors. We may ask for references to determine eligibility.
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