First Name

Last Name

Email

Phone Number

City/State

Role

Parent / Guardian

Educator

Community Leader

Other

Preferred Method of Contact

Text

Phone

Email

Child Information

Name

Birthday

Month

Day

Year

Opportunity

Other:

If known, what organization or business provides this opportunity?

If known, what is the estimated cost?

Tell Us About Your Child

What makes your child smile?

What activities or interests are they most excited about?

What strengths do you see in your child?

How do you believe this opportunity would benefit your child?

Financial Need - Which statement best describes your situation?

Without assistance, my child would not be able to participate.

Participating would create a financial hardship for our family.

We need assistance with registration or tuition.

We need assistance purchasing equipment or supplies.

Other

Anything Else?

Privacy & Communication

I certify that the information provided is accurate to the best of my knowledge.

Signature

Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.

Optional Story & Photo Permissions

Breaking Chains loves celebrating opportunities made possible through our community partners. Your child's privacy will always be respected.

Please select any permissions you are comfortable granting.

You may share my child's first name.

You may share our story.

You may use photographs of my child.

You may mention the opportunity received.

Please keep all information private.

(Choosing not to grant permission will never affect your child's eligibility.)

A Final Note

There are no perfect stories here.

We simply want to understand how this opportunity could make a meaningful difference in your child's life.

Thank you for trusting us with your story.

No matter the outcome, we hope your child continues to pursue the passions that make them uniquely who they are.

One opportunity.

One passion.

One chain broken.

Child Information

Tell Us About Your Child

Privacy & Communication

Optional Story & Photo Permissions

A Final Note

Breaking Chains Application Form