Cali's Gift has been provided by Cali's family in honor of her life and legacy to help others. This program is a part of The TEARS Foundation and financially assists parents whose child (ages 13-20) has died due to drug related issues or completed suicide.
After you submit this form, we will contact you within 48 hours to go over details. If you are only interested in emotional support, you only need to fill out section 1. If you are requesting financial assistance, we ask that you exhaust other options which may be available to you prior to applying for the financial assistance. If you need the application expedited or would like an update on the status of your application, contact Margaret Pilon, Program Director, at (732)610-8771 or firstname.lastname@example.org
Request for Assistance - WASHINGTON ONLY
Requested Assistance (choose all you wish to receive)
Grief Counseling Support (TEARS offers assistance for up to 8 counseling sessions with a professional grief counselor)
Funeral Assistance, including grave marker (Application must be received within 30 days after services have been provided)
Information on other services or activities offered by TEARS
Age at last birthday
Date of Incident
Location of death
Cause of Death, if known
Child's Ethnicity (for statistical purposes only)
How did you hear about the TEARS Foundation?
Parent Information (section 1)
Was child a legal dependent
If so, who was their legal guardian
Was child residing with a parent, other legal guardian, or independently
If independently or other legal guardian, what was the address (street, city, state, zip)
Preferred language spoken
Single - Living Together
Single - Not Living Together
List any siblings (with their ages), so we can better support your whole family during this difficult time.
Additional Information for Financial Assistance only (section 2)
If you are requesting information on non-financial services only, you do not need to fill out this section and may go directly to the end of the form and click submit.
Cali's Gift Financial Funeral Assistance Guidelines (only): Child is between 13 - 20 years old and died due to drug related causes and/or completed suicide. If you do not qualify under these guidelines, you may still utilize other TEARS services. Contact TEARS For more assistance (253) 200-0944 or email@example.com
Monthly Household Income
Annual Household Income
$0 - $16,000
$16,000 - $32,000
$32,000 - $65,000
If income is high, please explain any extenuating circumstances
So we can best assist you with your needs, fill out any other resources that may be available (choose all that may apply)
State Assistance (SSI, Food Stamps, etc)
Active Duty Military
Online Fundraising Page (set up by you or on your behalf)
Personal savings/credit card
If a fundraising page has been set up to assist with your funeral expenses, list the link here.
Type of services requested (chose all that apply)
Additional Information for Counseling Services Support (section 3)
If you are choosing funeral assistance only, skip this section and go to section 4.
Counseling services are provided through a TEARS approved counselor and need to be applied for through Cali's Gift within 6 months of child's death. If you have a counselor that is not on The TEARS Foundation's list of approved counselors, we can reach out to check with them on getting approved. Either have them contact TEARS at (253) 200-0944 or list their name and contact information and we will call them directly.
Have you chosen a counselor, if so give name and phone number
If you do not need funeral assistance you may skip the next section and choose submit.
Additional Information for Funeral Assistance (section 4)
Funeral Home (if chosen)
Funeral Director & Phone number (if known)
Funeral Home City & State
Have you already met with a funeral director
Date of Meeting (if known)
Name of Cemetery
Place and phone number where payment is requested
Amount Requested from TEARS or what is the balance, if other payments have been made.
Save & Return Account (optional)
New Users / Returning Users
to setup or return to your account for this form. Creating an account enables you to return to this form and your submitted results. An account will also enable you to partially complete this form and return later to finish. The account you establish is only for this form.