MJC Foundation Grant Application Form

Supporting Adolescents & Young Adults 17 - 30 years old to help conquer the growing challenges of Addiction, Depression, and Mental Health

"One Heart Touching Many"
Grant Application Form
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*
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*

MaleFemaleUS CitizenWhiteAfrican AmericanAsianHispanicAmerican IndianUnited States Veteran
How were you referred to us?.*

Treatment ProviderRecovery ResourceInternet SearchFriendFacebookOther
Do you consider yourself*

AlcoholicDrug Dependent / AddictAlcoholic & AddictSuffer from DepressionSelf Harm or Suicidal Tendencies
Substance Abuse History - Which substances have you used at any time in the past?*

AlcoholMarijuanaCocaineCrackHeroinOxycontin or OxycodoneMethamphetamineBenzodiazepine
Involvement in 12 Step Recovery- Check All That Apply*

I'm currently attending AA meetingsI'm currently attending NA meetingsI'm attending both AA and NA meetingsI would attend but cannot at this time because of treatment restrictionsI'm anxious to make meetings when I finish treatmentI have attended meetings in the past, but do not find them helpfulI have never attended a 12 step meeting
Do you own a copy of The Big Book?*

YesNo
Criminal History - Check All That Apply*

I have no criminal historyI have been charged with a violent crimeI have a Sex Crime convictionI am currently on probationI have committed or have been charged with arsonI'm on Ankle Monitoring
If you have answered yes to any of the criminal history questions above, state in detail the circumstances of the offense(s) - (Be through in your explanation)*

0/300
Sobriety / Clean Date - What Facility / City, State, Phone Number and Contact Person*

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. *

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? *

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.
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Supporting Adolescents & Young Adults 17 - 30 years old to help conquer the growing challenges of Addiction, Depression, and Mental Health

Grant Application Form

Personal Data

Applicant's E-Signature