Apply – Leiah's Mark

Help Your Child Move Forward. Apply today!

Simply follow these instructions:

Review our terms and conditions to ensure you qualify.
Complete the application below in its entirety.
Upload a copy of the death certificate of the parent or legal guardian lost to suicide. PLEASE BE SURE TO FIRST BLACKEN OUT ALL SOCIAL SECURITY INFORMATION.
Click the Apply Now button to submit the application.
Our board will review and respond within 60 days of submission.
If you have any questions, please feel free to Contact Us.

Adult Information

Your Name *

Relationship to Child *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Zip / Postal Code

Country

Phone *

Email *

How did you hear about us? *

Child Information

Child's Name *

Child's Age *

Birth Date *

Does this child live with you full-time? *

YesNo

If not full-time, what % of time is the child living wth you?

Has this child lost a parent or legal guardian to suicide? *

YesNo

Briefly tell us which sport(s) and/or activities, including any teams, clubs, or camps the child has participated in during the past 12 months. *

Please tell us which sport(s) and/or activities, including any teams, clubs, or camps the child applicant plans to participate in during the next 12 months. *

Please enter your estimate of the total cost to participate in these programs for the next 12 months. *

Please tell us how suicide has affected your household income, if applicable. *

Please tell us how partnering with Leiah's Mark will positively impact your child. *

Would you want to learn about other resources available to survivors? *

YesNo

File Upload of Death Certificate. PLEASE BE SURE TO BLACKEN OUT ANY SOCIAL SECURITY INFORMATION PRIOR TO SUBMISSION. *

Drop your file here or click here to upload You can upload up to 1 files.

By entering my name below, I state all information on this application is true and completed to the best of my knowledge, and I hereby agree to all terms and conditions. *

Full Name

Date *

Website