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 carmelenacares@gmail.com *
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 carmelenacares@gmail.com. Prior to doing so, please black out Personally Identifiable Information (PII) such as Social Security Numbers, bank account numbers, and bank routing numbers. *