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.
Email Address*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
County*
Example: Luzerne
Individual's Diagnosis*
Please attach documentation supplied from the Individual's doctor pertaining to diagnosis*

Cancelof
Item being requested: *
Have you tried to secure funding through the Individual's insurance company?*

YesNo
If yes, please attach denial letter*

Cancelof
Is the Individual enrolled in Medicare or Medicaid?*

YesNo
If yes, have you tried to secure funding through Medicare or Medicaid?*

YesNo
If yes, please attach denial letter.*

Cancelof
Is the Individual enrolled in MHDS?*

YesNo
If yes, have you tried to secure funding through MHDS?*

YesNo
If yes, please attach denial letter*

Cancelof
Have you attempted to get the requested item from insurance, Medicare or Medicaid, or MHDS?*

YesNo
If yes, please provide denial letter*

Cancelof
Does a physician or therapist believe this item could help the individual?*

YesNo
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*

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