Living Room Grants REFERRAL SOURCE INFORMATION Person making referral: Phone #: Email address: Referring organization: Organization address: How do you know the person you are referring? How long have you known the person you are referring? REFERRED RECIPIENT Name of referred recipient: Age: Adolescent (14-17)Youth (18-24)Adult (over 24) Gender identity (optional): Race/ethnicity (optional): Best way to contact recipient: MINI-GRANT INFORMATION Amount requested (up to $75): Date of request: Please describe how the proposed mini-grant fulfills the Foundation’s mission. How will a mini-grant change the recipient's circumstances? Will a mini-grant now be a temporary stop-gap for an ongoing need?