2023 Holiday Angels Application

Are you a registered Living Beauty? *

Yes
No

First Name *

Last Name *

Please use the email address that you receive Living Beauty emails from

Email *

Address 1 *

City *

State/Province *

Zip *

Phone *

Date of your most recent diagnosis? *

Approximate Annual Household Income *

Has your cancer impacted your household income? *

How many people are in your household? *

Source of Income *

Child/Spousal support
Disability
Income from a partner who is part of household
Other
Social Security
Unemployment
Wages from work

Has your cancer experience impacted your household expenses? *

(Optional) Please feel free to elaborate on the financial impact of your cancer experience.

Please consider me for the following (please choose all that apply) *

A Gift Card for a Holiday Meal
A Christmas Tree
Gifts for the Holiday
Gift Cards to Purchase Holiday Gifts and Other Items

If you would like to be considered for a holiday meal gift card, please let us know if you prefer in-store grocery shopping or grocery delivery service (i.e. In-person Shopping for Ralph’s or grocery delivery with Instacart).

If you are requesting gift cards, please list your preferred store.

Please list the names of your family members along with their wish list, clothing size and any other notes.

Applicant Signature *

I confirm that, to the best of my knowledge, the above information is true. I give my consent to the determination committee to review my personal information, as part of the decision-making process.

Acknowledgment *

By clicking this box and signing above I am indicating the funds will be used as requested above.