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Menu
Home
Who We Are
About Us
Our Partners
What We Do
What You Can Do
Resources
Q Convos Podcast
Resources & Reports
Violation Report Form
Services
Mental Health Therapy
Book A Doctor’s Appointment
Emergency Fund
Self-Test Kit Eligibility Form
News
Blog
Recent News
Contact Us
Menu
Home
Who We Are
About Us
Our Partners
What We Do
What You Can Do
Resources
Q Convos Podcast
Resources & Reports
Violation Report Form
Services
Mental Health Therapy
Book A Doctor’s Appointment
Emergency Fund
Self-Test Kit Eligibility Form
News
Blog
Recent News
Contact Us
Individual
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Applicant Details
Tell us about yourself
Applicant Full Name
*
First
Last
Email
*
Phone
*
Current Address
*
Employment Status
*
Employed
Self-Employed
Unemployed
Year of Birth
*
What is your sexual orientation? (pick only ONE)
*
Gay
Lesbian
Bisexual
Heterosexual
Pansexual
Asexual
Queer
What is your gender identity? (pick only ONE)
*
Transgender Man (you were born female, but identify as male)
Transgender Woman (you were born male, but identify as female)
Cisgender Man (If you were born male, and still identify as male)
Cisgender Woman (you were born female, and still identify as female)
Gender Non-Binary (You do not identify as strictly a man or a woman)
Intersex (you were born with sexual or reproductive anatomy that doesn't seem to fit the typical definitions of female or male)
Fund Request Details
Tell us what you need the requested funds for
Applicant Background Information (Please provide us with detailed information about you that can help us know more about you and the emergency requiring this support)
*
What are you requesting emergency funds for? Tick all that apply
*
Legal Representation - You need funds for legal representation
Medical Support - You need funds for medical support including hospitalisation and drugs
Other
How much do you need? (Write an exact amount of Naira in words)
*
Request Justification (Please provide information on why you need this support and any justification that can help the Application Review Board understand your request)
*
Provide as much detailed information as you can in not more than 800 words. If you are requesting for multiple reasons (e.g. Legal and Medical Support), make sure your justification covers all.
References
Please provide the contact details of two persons who can confirm who you are and your situation
Reference 1 - Name of Referee
*
Reference 1 - Email Address of Referee
*
Reference 1 - Phone Number of Referee
*
Reference 1 - What is your relationship with the referee?
*
Reference 2 - Name of Referee
*
Reference 2 - Email Address of Referee
*
Reference 2 - Phone Number of Referee
*
Reference 2 - What is your relationship with the referee?
*
Supporting Documents
Please provide documents that can support your request and provide legitimacy to your claims. For example, pictures of the event, medical bill/invoice or prescription, travel invoice. Only upload documents that are relevant to your request.
Upload Supporting Documents
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