Brighter Journeys' Grant Application

Brighter Journeys' Grant Application

Please complete the application below to be considered for grant funding. All required fields must be submitted for your application to be reviewed. Submission of this application does not guarantee funding. All grant awards are determined at the discretion of the Board. Please note we cannot do home modifications and if requesting a fence for elopement, we offer up to 200 linear feet of chain link fencing.
Today's Date

MonthDayYear
Date
Full Name

First NameLast Name
Individual this request will benefit:

First NameLast Name
Relationship to the Individual?
Example: Parent, Physician, Therapist, etc.
Individual's age
Contact Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
County
Example: Luzerne
Do you own or rent the address listed above?
Individual's Diagnosis
Please attach documentation supplied from the Individual's doctor pertaining to diagnosis

Cancelof
Item being requested:
Link of requested item (if applicable)
Additional comments on requested item
Have you tried to secure funding through the Individual's insurance company?
If yes, please attach denial letter

Cancelof
Is the Individual enrolled in Medicare or Medicaid?
If yes, have you tried to secure funding through Medicare or Medicaid?
If yes, please attach denial letter.

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Is the Individual enrolled in MHDS?
If yes, have you tried to secure funding through MHDS?
If yes, please attach denial letter

Cancelof
Have you attempted to get the requested item from insurance, Medicare or Medicaid, or MHDS?
If yes, please provide denial letter

Cancelof
Does a physician or therapist believe this item could help the individual?
If yes, please provide a note from the physician or therapist

Cancelof
If no, please describe why you think this item will help
How did you hear about us?
Signature
Should be Empty: