Southwest Virginia Trans Wellness Fund
For more information on the Trans Wellness Fund, the Southwest Virginia LGBTQ+ History Project, fund eligibility, and application process, see the fund's website here: https://swvalgbtqhistory.org/trans-wellness-fund/ 
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First Name and Last Name (This is your preferred name; a legal name is not required)  *
Phone Number (where we can reach you with any follow-up questions) 
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Email address (where we can reach you with any follow-up questions) 
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Which are the preferred ways we contact you? (check as many as apply) *
Required
Age (birth month and year; a specific day is not required)
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Race/Ethnicity 
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Gender (This is your gender identity; we do not care about legal sex) 
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Sexuality / Sexual Orientation (optional) 
City/Town or County of your current residence (We do not need your street address) 
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Zip Code of your current residence *
How long have you lived at the above residence? *
Funding request (any amount from $50 to $500)
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Budget (a detailed explanation of how you will use these funds. The more information the better, including any possible documentation of rent, bills, or transition-related costs. You will also have the opportunity at the end of this form to upload a PDF or JPEG document through an additional form if you would like to show any receipts, bills, or estimates for costs) 
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Supplemental funds (if the award amount will not fully cover your expenses, you can explain what other sources of funding you intend to use or apply for)
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