Equitable Care Fund Application

Equitable Care Fund Application

If you need assistance filling out this form, please call us at 401-300-5010

The equitable care fund is designed to grant people access to integrative therapies, and integrative medicine, that they would otherwise not be able to afford. The equitable care fund is supported by our collaborative, practitioners, local patrons, and donors. It is available to local residents of South Kingstown, and Narragansett, RI. It is also available to tribal members of any Native American Tribe.

You may apply to use available finds according to sliding scale to cover all or part of your desired wellness services. This sliding scale is only available as funds become available.

This form must be completed in its entirety to be considered. You must be at least 18 years of age.

SLIDING SCALE BENEFITS

Income / % covered when funds are avaliable

$21,000	90%
$25,000	80%
$29,000	70%
$32,000	60%
$36,000	50%
$40,000	40%
$43,000	30%
$47,000	20%
$50,000	10%

Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
What would you like to use the funds for?*

ReflexologyAuricular acupuntureIntegrative or Functional MedicineHealth CoachingReikiHerbalist ConsultationsOther
Please add anything you would like us to know here
Application Type*

Employment information
Name of Employer *
Phone Number of employer *
Please enter a valid phone number.
Address of employer *

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Please upload your license*

Cancelof
Please upload your most recent tax return *

Cancelof
Please upload your most recent pay stub*

Cancelof

Tribal Membership
The sliding scale covers 100 percent of wellness services when funds are available for tribal members. If you would only like to use a portion please note below.
File Upload

Cancelof
Contact Person*

First NameLast Name
Phone Number*
Please enter a valid phone number.

Attestation

I attest that I have filled out this application completely and honestly.
Name

First NameLast Name
Date

MonthDayYear
Date
Signature

Clear
Should be Empty:

Equitable Care Fund Application

Employment information

Tribal Membership

Attestation