Please provide a short paragraph describing your request for assistance and how it will benefit your child
Child's Name *
Child's Name
Parent/Guardian Name *
Parent/Guardian Name
Only needed if different from above
Phone # *
Phone #
Name, Number & Address
Name, Number & Address
Name of Establishment, First and Last name of therapist or teacher, address of establishment, phone number of establishment
i.e. we are requesting a bike because...
How will our donation help your child?
Has a doctor prescribed this type of assistance? *
Can you provide a doctor’s recommendation and/or prescription for this particular form of assistance and a doctor’s description of how this assistance will benefit the child? If yes, please email copies of such documentation to *
To help demonstrate your family’s financial need to the Carmelena Cares, Inc. Board of Directors, would you be willing to provide them with a copy of pages 1 and 2 your most recent Federal Tax Return? If so, please email those copies to Prior to doing so, please black out Personally Identifiable Information (PII) such as Social Security Numbers, bank account numbers, and bank routing numbers. *