Pearl's Memory Babies Application

This application is for care facilities serving memory care residents that would like to be considered for a donation.

Facility Name

First Name

Last Name

What is your job title at your facility:

Phone Number:

Facility Name:

Address Line 1:

Address Line 2:

Country

State

City / Town:

ZIP / Postal Code:

Has this facility received a donation from Pearl's Memory Babies before?

Yes No

Does this facility have a unit dedicated specifically to memory care? (A "no" answer does not disqualify.)

Yes No

Please provide total number of memory care residents as each person will receive a donation from Pearl's Memory Babies. (If your facility serves non-Memory Care residents, please know we would love to donate to the entire facility; however these donations are designated for residents struggling with memory disorders. )

Pearl's Memory Babies is unable to offer this opportunity without the generosity of our donors. Do you agree to allow photos and videos of residents (ones having photo release waivers/permission) receiving their delivery for various media distribution outlets, including social media, so that our donors can see how their donations are making a positive difference for the memory community? This will require signed waivers to be returned quickly. This is the only way Pearl's Memory Babies can continue forward.

Yes No

How do you envision this donation assisting your memory community? Please tell Pearl's Memory Babies why you believe this donation is important for your memory care residents (multiple lines of text can be typed.)

Selection Process Pearl's Memory Babies applicants are not automatically awarded and are selected by Pearl's Memory Babies' Board of Directors. Awarded applicant/Facility will be notified at the contact information provided here. Applicants must promptly complete signing and returning of all requested waivers, provide updated count of memory care residents, and attend online meeting with Pearl's Memory Babies; otherwise the donation may be cancelled by Pearl's Memory Babies and another facility/recipient selected.

I understand

Address Line 1:

Address Line 2:

Country

Province:

City / Town:

ZIP / Postal Code:

Pearl's Memory Babies Application

Pearl's Memory Babies is a 501(c)(3) nonprofit organization. EIN: 82-4470082