Butch’s Night Out Application - Outer Banks Relief Foundation

Please tell us about yourself and your loved one and the outing that you would like to take in Butch’s Spirit:

Name*
First Last
Physical Address*
Street Address Address Line 2 City State ZIP Code
Mailing Address*
Same as Physical Address

Street Address Address Line 2 City State ZIP Code
Email Address*
Phone Number*
Please describe the challenging circumstances that have made a celebratory night out (or night in, or lunch out, etc.) a welcomed and uplifting treat for you and your loved ones*
Describe the outing you would like to take with your loved one and who will be on the outing*
What is the estimated cost for your outing?*
When would you like to take your outing? Indicate month/year, date, or season (Fall, Spring, etc.)*
How did you hear about Butch’s Night Out?*
Please provide a reference for your application including their name, relationship, phone number and email. This reference may be a social worker, health care provider, teacher, etc.*
When you apply, you acknowledge that Nicole Close, Chris Albrecht and the Outer Banks Relief Foundation are not liable for anything that happens when you participate in your event. We are merely providing the funds and planning services.