MJC Foundation Grant Application Form

Supporting Women and Men, 17 - 30 years old making the transition from rehab to sober living, and conquering the growing challenges of Addiction, Depression, and Mental Health

"One Heart Touching Many"
Grant Application Form - *If you are making the move from rehab to sober living in the next 30 days, please proceed.*
Provide as much information as possible. Incomplete applications will not be considered. Let your efforts in this reflect your desire for recovery. The information you provide is confidential and will never be shared or sold.
Personal Data
Full Name

First NameLast Name
Birthdate

MonthDayYear
Mobile No
Format: (000) 000-0000.
Email
Where the confirmation will be send to
Current Residence

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Optional Information

Information regarding gender, ethnic origin and race are optional. The information is requested for post-grant report generation only and in no way affects your selection for grant awards. However, providing this information may increase your opportunities for grants where donors have asked that priority consideration be given to applicants meeting certain demographic criteria (such as minority status, criminal history, etc.)
Choose All That Apply
How were you referred to us?.
Do you consider yourself
Substance Abuse History - Which substances have you used at any time in the past?
Involvement in 12 Step Recovery- Check All That Apply
Do you own a copy of The Big Book?
Criminal History - Check All That Apply
If you have answered yes to any of the criminal history questions above, state in detail the circumstances of the offense(s) - (Be thorough in your explanation)

0/300
Sobriety / Clean Date - What Facility / City, State, Phone Number and Contact Person (incomplete applications will not be considered)

0/500
What are some of the challenges you have faced on your road to sobriety / recovery?

0/500
If you were referred to us by a treatment provider, what was the name of the facility and the contact person that referred you. (incomplete applications will not be considered)

0/300
What is the name of the facility and what is the name of the contact person and phone number at the facility you will be living at? (incomplete applications will not be considered)

0/300
What is motivating you to pursue sobriety, and what is your specific plan?

0/500
How would a Michael James Cotton Foundation grant be helpful?

0/500
What dollar amount are you requesting?

0/500
Is there anything else you would like us to know?

0/500
Applicant's E-Signature
By signing the space below, you are certifying that all information is correct and that you are the person completing this application. When you press the submit button, you will receive an email confirmation that your application was received. Please print for your records and retain as verification of your application.
Signature
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Supporting Women and Men, 17 - 30 years old making the transition from rehab to sober living, and conquering the growing challenges of Addiction, Depression, and Mental Health

Grant Application Form - *If you are making the move from rehab to sober living in the next 30 days, please proceed.*

Personal Data

Applicant's E-Signature

Grant Application Form - If you are making the move from rehab to sober living in the next 30 days, please proceed.