Thrive Wellness Collective Grant Application
Thrive Wellness Collective is a 501(c)3 non-profit organization that is focused on helping everyone in our community receive an individualized approach to pre and postnatal care. This application will allow us to get to know you and your specific needs. Each application requires the following information:❊ Your personal contact information❊ Household income verification❊ A short video clip, under one minute, describing the importance of birthing with us❊ Participate in sharing your experience and authorization for social media platforms
Name:
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First Name
Last Name
Partners Name (if applicable):
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First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone number:
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Partners Phone number:
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Email:
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Partners Email:
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Do you currently qualify and have full Medi-Cal?(other than pregnancy Medi-Cal)
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Yes
No
Upload a video introduction describing the importance of birthing with us. (Please keep under one minute):
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Income verification:
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Were you referred to Thrive by a practitioner that practices out of Tourmaline? If so, list name here:
What services are you requesting?
Please share any special circumstances you feel the Thrive board should be aware of:
Date
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Month
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Day
Year
Date
FINANCIAL WORKSHEET
Applicant
Partner
How many people in the household:
Please fill out expenses for both parties: (combine)
Rows
Monthly Expenses $
House Rent/Mortgage Payment
Property Taxes
Homeowner's Insurance
Homeowner's assoc. fees
2nd Mortgage
Credit cards (min. monthly pmt)
Student Loans
Tuitions
Other loans
Car Loan
Automobile Insurance
Car gasoline
Car maintenance
Home phone expenses
Cellular phone
Cable / Internet
Home Electricity
Home Gas
Sewer / Water
Garbage
Groceries
Uniform (dry clean)
If Not Deducted by Employer:
Health Insurance
Life Insurance
Alimony / C ild Care Expenses
(Not Insured) Medical bills
(Not Insured) Medications
Church (donations)
Membership dues
Other expenses
Rows
Monthly $
Applicant Gross Salary
Net Salary
Partners Gross
Net Salary
Alimony / Child Support
Pension/Retirement
Disability/Food Stamps
Room Rental income
Rental property income
Other (Contribution)
Rows
Available Funds Today
Checking account
Savings account
Other
Total Available
$ You can pay towards your care
$ Partner to pay towards care
$ Family can offer towards care
Total Monthly Expenses
Total Monthly Income
Final Net Numbers (+/-)
Applicant:
Date
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Month
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Day
Year
Date
Partner:
Date
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Month
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Day
Year
Date
Submit Application
Submit Application
Should be Empty: