submit a need

Let us know what it is you need, and let Chosen meet your need without embarrassment, scrutiny, or overhanging expectations.

Name

First Name

Last Name

Email Address

Phone

(###)

###

####

Address

Street Name

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Write a brief summary of your need.

Describe your personal situation, what type of donation you prefer (a monetary value or specific items), and how this donation will help you.

Allow Chosen.org to use your name to raise awareness of your need.

Note that if you choose "Anonymous story", the details of your situation will still be used, but your name will remain private.

Use my name

Anonymous story

How did you hear about us?

I was referred by:

(Individual/organization who referred you to Chosen.)

If you have a personal fundraising page, please provide the link:

Please provide you/your family members' LinkedIn profile links.

Please list any organizations you/your family are members of.

(I.e. Churches, military, leagues, social groups, professional organizations, etc.)

Is there a cause you would like us to raise awareness of through your need?

I hereby grant Chosen.org, Inc. permission to use my likeness in a photograph, as well as details regarding my personal narrative, in any and all of its publications, including any website and internet materials, without payment or any other consideration. I understand and agree that these materials will become the property of Chosen.org, Inc. and will not be returned. I hereby irrevocably authorize Chosen.org, Inc. to edit, alter, copy, exhibit, publish or distribute my photo and details regarding my personal narrative, including any information submitted by me in my application or any other materials I submitted to Chosen.org, Inc., for purposes of publicizing Chosen.org, Inc.’s programs, soliciting donations, or for any other lawful purpose. In addition, I waive the right to inspect or approve the finished product, including written or electronic copy, wherein my likeness or details regarding my personal narrative appear. Additionally, I waive any right to royalties or other compensation arising or related to the use of my photograph or personal narrative. I understand that Chosen.org, Inc. is not responsible for any inaccuracies in my personal narrative, whether they are provided by me or due to the mistake of Chosen.org, Inc. I hereby hold harmless, release, and forever discharge Chosen.org, Inc. from all claims, demands, and causes of action which I, my heirs, representatives, executors, administrators, or any other persons acting on my behalf or on behalf of my estate have or may have by reason of this authorization, or arising from Chosen.org, Inc.’s use of my photograph or personal narrative. I am 18 years of age and am competent to contract in my own name. I have read this release before signing below and I fully understand the contents, meaning, and impact of this release.

By entering your full name below, you consent to the above.

Date

YYYY