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Review of your application can take up to 1-2 weeks. If you prefer to print, fill out and email, click here to print the application form. Completed applications can be emailed to

Please fill out the below application if you are nominating a loved one or yourself. 

Select all that apply.

What type of experience are you looking for

Family Giveaway Option

North Conway Adventure

1 night hotel stay.

Passes to the Water Park for 2 adults and up to 3 children

$350 for Meals and travel


Boston Adventure

1 night hotel stay

Train tickets from Portland to Boston (optional)/or $100 towards gas and parking

$350 for meals



Please let us know if there is another destination you would like to visit.

Select an option

Girs/Boys Trip OR Getaway with your Spouse

Girls/Boys Trip OR Getaway with your Spouse

Please Circle One


Spa day

2-3 services each for 2 people

Ex: Facial & Massage plus manicure or pedicure)

Lunch or Dinner for 2


Boston Weekend Away

1 night hotel

Train tickets or $100 towards gas and parking

A Spa Service OR tickets for a show OR Sporting Event

$250 towards meals


Midcoast Weekend Away

1 night hotel 

$50 towards gas and parking

A Spa Service OR Harbor Sail Cruise

$250 towards meals


Private Chef

6-8 friends provide a 3 course private dinner

Include 3 bottles of wine



Please be specific if this is something else you would enjoy.

Select an option
We sometimes are asked by media (press/Instagram/Facebook/Twitter) for personal stories from the people we have helped. If you qualify, would you be willing to share how this foundation has helped you or have your story be written about.

Please remember to fill out all questions above and include your signature before your application can be processed and reviewed for the next step.

Thanks for submitting!