Today's Date

Grant Recipient's First Name (If you are a caretaker of a minor, please put YOUR name and fill out from YOUR perspective)

Grant Recipient's Middle Name or Initial

Grant Recipient's Last Name

Email

Grant Recipient's Date of Birth

Address

Address Line 2

City

State

Zipcode

Phone Number (numbers only, no symbols)

What is the best way to get in contact with you? (Hold ctrl to select multiple options) Email Phone Text Other

Are you of Hispanic, Latino, or Spanish origin? No, not of Hispanic, Latino, or Spanish origin Yes, Mexican, Mexican-American, Chicano Yes, Puerto Rican Yes, Cuban Yes, another Hispanic, Latino, or Spanish origin Prefer not to state

What is your race? Black or African American White Asian American Indian or Alaska Native Native Hawaiian or Pacific Islander Multiracial Prefer to self-describe Prefer not to state

Please describe the race you identify as.

What gender do you identify as? Man Woman Transgender Non-Binary Genderqueer/-fluid Cisgender Prefer to self-describe Prefer not to say

Please describe the gender you identify as

What sexual orientation do you identify as? Heterosexual Lesbian Gay Bisexual Queer Asexual Prefer to self-describe Prefer not to state

Please describe the sexual orientation you identify as.

Have you ever served on active duty in the U.S. Armed Forces? Never served in the military Only on active duty for training in the Reserves or National Guard Now on active duty On active duty in the past, but not now Prefer not to state

Have you ever been part of or applied for another LPP program in the past? YES NO

Are you currently incarcerated for cannabis OR have you been released in the past year for a cannabis offense? YES NO

Please provide your Inmate ID

Are you the child of someone who is currently incarcerated for a cannabis related offense? YES NO

Are you the primary caretaker for the child of someone currently incarcerated for cannabis? YES NO

Are you another family member of a constituent who is applying for the WAITLIST option? (See details at the top of the page.) YES NO

If you are filing on behalf of a loved one, or are a child or caretaker to a child of a parent currently incarcerated, please list the name of the currently incarcerated individual and their Date of Birth.

Please list the incarcerated individual's Inmate ID#

What state is the incarcerated person originally from? Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington D.C. West Virginia Wisconsin Wyoming

What is the incarcerated person's hometown?

Please describe your experience with being incarcerated or having a loved one incarcerated for cannabis. If you are a caretaker, please also include your relationship to the constituent & the child's full name and DOB.

Please describe any financial hardship you are currently facing.

Please describe how a grant from LPP would benefit you.

Funding request (up to $1,000 can be requested). Please enter numbers only, no symbols.

Are you also seeking employment? YES NO

Are you interested in seeking employment in the cannabis industry? YES NO

Are you interested in cannabis education courses? YES NO

Are you interested in employability trainings (including resume building and interview skills)? YES NO

What is your preferred t-shirt size? XS S M L XL

Would you be willing to share your story with LPP and be featured in our communication channels? (This does NOT impact your application in any way.) YES NO

Would you be interested in a phone or video call to share more of your story with LPP? YES NO

Is there anything else we should know about you?

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