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Apply for
peacock picks

Please note the information provided will remain confidential and will not influence your eligibility for funding. It is intended solely for internal demographic analysis. 

Child's Date of Birth
Month
Day
Year

Please list all applicable diagnoses

Parent / Guardian Date of Birth
Month
Day
Year
Preferred Method of Contact

If different from above

Do You

Please include name of business, current position, and how long employed

Spouse / Partner Date of Birth
Month
Day
Year

Please include name of business, current position, and how long employed

Please list names and ages of siblings if applicable

Please provide a summary of your monthly expenses. i.e. utilities, auto expenses, medical, dental, food, clothing, child care, etc.

Please provide a detailed description of what services / therapies you need financial assistance for and how much you are needing for each service

Do You Authorize The Little Peacock Project To Use Photos Of Your Child?

If accepted, we would like to feature your child and their story on our website and social media. Please provide photos by uploading them below

please upload up to 4 photos

By submitting this application, I agree that any funds received through the Peacock Picks program will be allocated to therapy services, medical expenses, equipment, or other necessary support for my child with special or medical needs.

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