Form

C.A.R.E. Application for Assistance
Name*

First NameLast Name
Address*

Street Address

CityState / Province

Postal / Zip Code
Email Address
example@example.com
Phone Number*
Please enter a valid phone number.
Requested Amount *
(note: Any individual receiving over $599.00 will be issued a 1099) Grants will be paid directly to a vendor or service provider whenever possible. Receipts may be requested under certain circumstances.
Purpose of Request:*

Household Members

Monthly Household Income

Monthly Household Expenses

Community Resources you have reached out to

Household Member(s) with health insurance

Are you willing to reach out to other community resources

YesNo
Please provide any additional information or explain any special circumstances that you feel will help C.A.R.E. in their decision about this request.
Do you agree to allow C.A.R.E. to make referrals to other community resource agencies on your behalf and/or to contact other agencies as recommended by C.A.R.E.?

YesNo
Would you agree to volunteer at a C.A.R.E. event to help pay if forward?

YesNo
*Repayment of this grant in any amount will be utilized to assist others with a hand-up*
I hereby make application for assistance from C.A.R.E. and certify that this information is correct and true to the best of my knowledge. I authorize C.A.R.E. to futher discuss my request with other community agencies that may be able to assist me. I also authorise C.A.R.E. to verify or obtain information that is relevant to this request for assistance.
Applicant Signature

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C.A.R.E. Application for Assistance