Success Fund Application Form

Success Fund Application Form

Is something preventing you from: becoming a caregiver/DCW, continuing to provide care, or returning to the direct care field? The Success Fund is a Financial Assistance Fund for Direct Care Workers (DCW) & all (family, agency, and private) Caregivers. How can we help you succeed today? Fill out the application below and submit it by JotForm, Email: kara.gear@caregiverincentiveproject.org, or USPS mail: PO Box 637 Marquette, MI 49855 today. If you have any questions, please don't hesitate to reach out to our team!
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Upper Peninsula County of residence:*

AlgerBaragaChippewaDeltaDickinsonGogebicHoughtonIronKeweenawLuceMackinacMarquetteMenomineeOntonagonSchoolcraftOther
Upper Peninsula County(ies) of employment:*

AlgerBaragaChippewaDeltaDickinsonGogebicHoughtonIronKeweenawLuceMackinacMarquetteMenomineeOntonagonSchoolcraftOther
Email*
example@example.com
Phone Number*
Please enter a valid phone number to reach you.
Survey
Please select your age range:

18-2425-3435-4445-5455-6465-7475+
What is your gender identification?

FemaleMalePrefer not to answer
What is your household annual income range (including all employment)?

$9,999 or less$10,000-$24,999$25,000-$49,999$50,000-$74,999$75,000-$99,999$100,000 or morePrefer Not to Answer
What is your employment status as a caregiver? (check all that apply)

Employed Full-timeEmployed Part-timeSelf-employedUnemployedLooking for a jobStudentRetiredPaid Family CaregiverUnpaid Family CaregiverLooking to get into the FieldOtherPrefer not to answer
What category would you fall under being employed as a caregiver? (check all that apply)

Private dutyHome care agency employedFamily caregiver (paid or unpaid)Adult Foster Care (AFC) employedHospice agency employedAssisting living employedNone of the above
Please select your years of experience:

0-3 years3-5 years5-10 years10-15 years15-20 years20+years
Please check if you fall into any of the following categories: (check all that apply)

Military MemberFamily/Partner of Military MemberTribal Community MemberRetireePerson with DisabilitiesImmigrantHigh School StudentCollege StudentN/A
Application
Please share your reason for applying:*
Based on your explanation above, what range of assistance are you looking for?

$0-$50$50-$100$100-$150$150-$200
Please provide the actual amount below:*
Please upload a photo or scan of receipt:

Cancelof
By checking the box below, I understand I have to provide a receipt within two weeks of receiving the check, if one is not provided now.*

Yes
Please upload a photo or scan of Personal ID:*

Cancelof
What category would your barrier fall under?

TransportationChildcareFamilycareEldercareInitial work supplies/prep (any screenings/work attire)Training
By checking this box, I verify that all of the information provided above is true.*

Yes
Funding is made possible through a grant awarded to MSU IMPART Alliance from the Michigan Department of Health and Human Services using American Rescue Plan Act/Home and Community Based Services Spending Plan funds.
Should be Empty:

Success Fund Application Form

Survey

Application

Funding is made possible through a grant awarded to MSU IMPART Alliance from the Michigan Department of Health and Human Services using American Rescue Plan Act/Home and Community Based Services Spending Plan funds.