P2G Assistance Application Form
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How Did You Hear About P2G? Social MediaInternetOther
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Language: EnglishEspañol
I Need Assistance With: ElectricityGasWaterRentOther
Amount:
I certify that I will not withhold any information that would unfavorably affect my application to receive assistance from Passion2Give. I understand that information contained on my application will be verified by Passion2Give, and any misrepresentation(s) may be cause for my immediate rejection to receive assistance from Passion2Give.
I AgreeI Disagree
Rights and Waiver
I hereby authorize Passion2Give to photograph, record video, and/or interview me if necessary. I understand that these materials may be used in Passion2Give’s publications, including web-based content, for promotional and awareness purposes.
I acknowledge that participation in media is completely voluntary and may not be applicable in certain circumstances to ensure the privacy and safety of individuals. I agree to the terms and conditions
Electronic Signature: (Please type full name) Date: