EmailMe Form - Request for an Individual Account

Name of Guardian or Parent (if individual is a minor) *

First Last

Name of Individual *

First Last

Email *

Phone *

### - ### - ####

Today's Date: *

MM / DD / YYYY

Address

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Requested uses of the funds donated to the account:
(examples: conferences, therapy, training for at-home therapy, etc) *

Please agree to the following: *

I/we are applying for a matching gift from Bridge to Healing

I/we understand that 25% of all donations made to this account are considered a contribution to Bridge To Healing

I/we understand that all donations made to this account through PayPal will be reduced by 2.5% to cover the PayPal expense

I/We understand that requests for disbursements must be accompanied by an invoice detailing what the disbursement is for. Dates of service for the invoice must be within 30 days prior to the submission of the Request for Funds from Account form.