Request for Assistance form

When you complete this Request for Assistance, we will assess the needs of the applicant and attempt to devise a plan of action. We’ll likely enroll the applicant in an on-line and telephone counseling program and may assign a volunteer mentor to the child to provide motivation and support throughout the process. Our assistance might include getting the child started with a gym or health club membership, or sessions with a dietician or nutrition counselor.

Please fill out the form below and we’ll be in touch! Alternatively, you may download the form here and fax or mail it in to us.