Heart and Hope Application Applicant Information * First Name Last Name Applicant’s Role: Self Family Member / Friend (applying on behalf of someone else) Relationship to Recipient Phone * (###) ### #### Email * Address Address 1 Address 2 City State/Province Zip/Postal Code Country Full Name of Recipient * First Name Last Name Age 18-25 years 25-40 years 40-50 years 50+ City, State of Residence * This fund is for North Carolina residence. Number of Dependents * Description of Need Brief Summary of Circumstances * Tell us about your or the recipient's current challenges and why assistance is needed. Specific Needs Being Requested (check all that apply) Childcare Transportation Groceries, Food Medical Expenses Utilities Housing Assistance Other Thank you for your application! Someone from our team will get back to you shortly.
