Holiday Angels
First Name *
Last Name *
Email *
Please use the email address that you receive Living Beauty emails from.
Address 1
City
State/Province	AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingAmerican SamoaFederated States of MicronesiaGuamMarshall IslandsNorthern Mariana IslandsPalauPuerto RicoU.S. Minor Outlying IslandsVirgin IslandsArmed Forces AmericasArmed Forces Europe, the Middle East, anArmed Forces PacificAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNova ScotiaNorthwest TerritoriesNunavut TerritoryOntarioPrince Edward IslandQuebecSaskatchewanYukon Territory
Zip
Phone
Date of your most recent diagnosis?
Approximate Annual Household Income *	$25K or less$25-40K$40-60K$60-80K$80-100K$100K +
Has your cancer impacted your household income? *	No. Income has not been impacted.Yes. Income dropped 25%Yes. Income dropped 26-50%Yes. Income dropped 51-75%Yes. Income dropped 76-100%
Source of Income (Select Range) *	Child/Spousal support Disability Income from a partner who is part of household Other Social Security Unemployment Wages from work
How many people are in your household? *	123456789
Has your cancer experience impacted your household expenses? *	No. Expenses have not been impacted.Yes. Expenses increased 10-25%Yes. Expenses increased 26-50%Yes. Expenses increased 51-75%Yes. Expenses increased 76-100%
Please feel free to elaborate on the financial impact of your cancer experience or anything else you think we should know. (i.e. if you have been financially affected by COVID-19) *
Please considering 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 list your closest market.
If you are requesting other gift cards, please list your preferred store.
Family Member Wishlist. Please list the names of your family members along with their wish list, clothing size and any other notes.
Applicant Signature *	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.
Acknowledgement *	By clicking this box and signing above I am indicating the funds will be used as requested above

Please note that we may not be able to fulfill all wishes. Applications will be prioritized based on need.