Grant Application

Avamere Family Foundation Grant
Section 1: General Information
Name *

First Name Last Name
What are your preferred pronouns? She/hers, he/his, they/them, choose to not disclose?
Phone Number *
Please enter a valid phone number.
Email *
example@example.com
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Employee ID *
Job Title *
Community Location *
Do you work in a Covid unit? *

Yes No
If you do not work in a Covid unit, is your facility currently experiencing an outbreak? *

Yes No
Work Phone Number *
Please enter a valid phone number.
Work Email *
example@example.com
I am a: *
Date of Hire *

Month Day Year
Date of Departure *

Month Day Year
Name of Deceased *

First Name Last Name
Date of Death *

Month Day Year
I work: *
Section 2: Financial & Household Info
How many days of work have you missed? *
Annual Salary/Hourly Wage of Employee *
Total Household Income per year *
Number of People in Household *
Estimated out-of-pocket expense of this medical event?
Estimated loss of income?
Number of Children Under Age 18 Living in Household *
Section 3: Grant Request
Grant Amount Requested: Grant requests cannot exceed $1,000. *
Grant amount requested? Cannot exceed $1,000: *

$500 (minimum) $750 $1,000 (maximum) Other
How do you plan to use these funds? Select all that apply. *
Has insurance covered any amount of this emergency need? *

Yes No
Describe your emergency need in detail. *
I have filled out this application truthfully and to the best of my knowledge. *

True
Are you willing to share your story? *

Yes No
You may be asked to provide additional documentation of the event and related expenses. For additional information, please review the grant criteria or email Grants@AvamereFamilyFoundation.org.
Should be Empty:

Avamere Family Foundation Grant

Section 1: General Information

Section 2: Financial & Household Info

Section 3: Grant Request