Spoonies Unite Nonprofit Pilot Program Application

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Please complete the following form, and email for any questions! Thanks :)

Name *

First and last name

Email *

Phone number *

Where are you located? City & State. *

Are you willing to have your story shared publicly to bring more awareness to our nonprofit? *

Yes

Required

Tell us about yourself- what is your chronic illness/disability/condition? Please be specific. *

Roughly what is your yearly earned income? *

$0-$25,000/yr

$25,000-$50,000/yr

$50,000-$75,000/yr

Over $75,000/yr

How will you use your financial gift from Spoonies Unite Nonprofit? Please be as specific as possible. *

This is our 'Pilot Program' which means we will use your experience receiving this financial assistance as a way to gain further support towards our cause. This will require you to answer several questionnaires over several months (after having received the money), and perhaps provide photos for our website, etc. Are you willing to participate in that? *

Yes

Maybe

Submit

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