Essentials Box Nomination Form

Each year, Thanksgiving and Christmas brings relief to millions of people living below the poverty line. But what about January through October?

During the non-holiday months, over 37 million people still need help meeting their essential needs. If you know someone who is In Need Of basic essentials, please complete the form. Recipients can remain anonymous.

Your Information

Start by entering your information below. If you are nominating someone, you will enter their information in the "Nominee Information" section below.

Your Name

First Name

Last Name

Your email address

We will contact you regarding your nomination.

Your Phone Number

(###)

###

####

Nominee Information

Use the fields below to self nominate or nominate an individual for the essential box. Their information will remain anonymous unless otherwise stated by the recipient.

Nominee's Name

First Name

Last Name

Birthdate

YYYY

Grade Level

Shirt Size

Pant / Short Size

Shoe Size

Favorite Shoe Brand

Any additional information you'd like us to know?

Does this candidate have siblings that lives in the same household?

Yes

Please list a few of the candidate's interests (i.e. sports, music, television shows, games, books, etc.)

Essentials Box Qualification

Please share background information on the nominee and why you believe they will benefit from the In Need Of Essentials Box.

Age

If you're not sure of the birthday, enter their approximate age here.

Essentials Box Nomination Form

In Need Of_______.