Grant Program Application Form

Caregiver Support Grant Application

$2,000 Per Family Per Year
*Important Note for Applicants: This program is designed to provide temporary relief to family caregivers from the ongoing demands of caring for a loved one. All information provided will be kept confidential and used solely to determine eligibility for the Respite Grant Program. Privacy Statement: The Greater Lansing Care Foundation is committed to protecting your privacy and the privacy of the care recipient. All personal health information (PHI) collected through this application will be handled per the Health Insurance Portability and Accountability Act (HIPAA) and other applicable privacy laws. By submitting this application, you consent to the collection and use of this information for the stated purpose
1. Caregiver information

Please fill out the below information.
Total Grant Funding Requested:
$2000 max
Caregiver's Full Name*

First NameMiddle Initial Last Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth

MonthDayYear
Date
Phone Number*

Country CodeArea CodePhone Number
E-mail*
example@example.com
Realationship to Care Recipient *

2. Care Recipient Information

Please answer the questions to the best of your ability.
Care Recipient's Full Name*

First NameMiddle Initial Last Name
Date of Birth

MonthDayYear
Date
Diagnosis:*
(e.g., Alzheimer’s, dementia, etc.)
Date of Diagnosis*

MonthDayYear
Date
Living Situation (Check One)*

In caregiver’s homeIn care recipient’s homeAssisted living/nursing homeOther: ___________________

3. Grant Use Summary

Please follow the instructions below.
Please check all the ways you intend to use this grant (optional):

Residential Respite CareHome health aide or in-home assistanceAdult day program or memory café feesTransportation to medical appointmentsHome safety modificationsSupplies or equipment related to caregivingOther (please specify below)
Other details
Caregiver Statement of Need
Please provide a detailed explanation (at least 200 words) as to why you are requesting this grant. Include your caregiving responsibilities, the emotional and financial toll of caregiving, and how this grant would impact your ability to provide care.*
(You may attach additional pages if needed.)

Signature and Acknowledgment

I affirm that the information provided in this application is true and complete to the best of my knowledge. I understand that the Greater Lansing Care Foundation may request additional documentation and that submission of this application does not guarantee approval.
Signature
Should be Empty:

Caregiver Support Grant Application