Recovery Capital Grant Application

Recovery Capital Grant Application

*Any grants awarded are paid directly to the service provider.*Please note, this micro grant is for local residents only (Hastings, Cottage Grove and Redwing.) If you have any questions or would like to know if we cover your area, please contact us. The intention is to grow capital within our local community of recovery.
Date*

MonthDayYear
Date
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Gender*

MaleFemale
Date of Birth*

MonthDayYear
Date
Employment Status*

Full TimePart TimeNot Employed
Other Sources of Income

Disability
Are you a person that identifies with being in recovery?*
What is your recovery status?

Long TermShort Term