JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Eva Lee Parker Fund Support Request
NOTE: WE ARE CURRENTLY UNABLE TO DISTRIBUTE FUNDS. PLEASE CHECK BACK AFTER THE NEW YEAR FOR UPDATES.
This form is for Black women who are currently experiencing domestic violence and are in need of financial support.
If you would like to donate to the fund visit
https://www.thesanctuaryinthecity.org/evalee/
.
For more information visit
https://www.courageousshift.com/evaleeparkerfund
.
*Please note: all requests may not be approved for the full amount.
* Indicates required question
Email
*
Your email
First Name
*
Your answer
Last Name
*
Your answer
Email Address
Your answer
Best number to contact you
*
Your answer
In order to better serve you, may we contact you via text, call, or email?
Yes
No
Clear selection
City & State Located
*
Your answer
Requesting funds for...
*
Transportation to escape (bus, train, or plane ticket, gas for car)
Broken items in the home (windows, doors, walls, etc.)
Items for children (diapers, clothing, formula, food, etc.)
Personal items needed to leave (clothing, sanitary napkins, disposable phone)
Fee for lock changes
Other:
Required
Amount request
*
Your answer
Payment method to receive funds
*
CashApp
Venmo
PayPal
Payment method information (e.g. email, username, handle)
Your answer
Anything else you would like for us to know?
Your answer
How did you hear about the Eva Lee Parker Fund?
*
Your answer
Submit
Page 1 of 1
Clear form
Never submit passwords through Google Forms.
This form was created inside of Courageous Shift.
Report Abuse
Forms
