APDA Northwest Financial Hardship Fund Application

APDA's mission: Every day, we provide support, education, and research to help everyone impacted by Parkinson's disease live life to the fullest.

APDA Northwest is pleased to offer a Financial Hardship Fund to assist people with Parkinson's disease (PD) experiencing financial difficulties in WA, OR, ID, MT or AK. Approved applicants can receive $400 once every twelve (12) months. The funds are intended to help improve the quality of life of people with PD.

Applications are reviewed on a rolling basis. Awards are made on a first-come basis and are subject to the approval of this application and the availability of funds. The fund is subject to change or discontinuation with limited notice.
Eligibility Guidelines

To be considered for an award, the applicant:
- Attests to having a diagnosis of Parkinson’s disease or Parkinsonism.
- Attests that they have not received funds from APDA within the last 12 months.
- Understands this fund is intended to support persons with Parkinson’s disease who are experiencing financial hardship and is not intended as an ongoing support fund. (For help in exploring additional local community resources, please contact APDA.)
- Will complete and submit the entire application.
- Will complete a post-experience survey that helps APDA analyze feedback/needs of the PD community.
- Resides in the community, not in rehabilitation centers, long-term care, or skilled nursing facilities.
- Understand that the payment may take at least 30 days to process after the application is approved.
If you have any questions, don't hesitate to contact APDA Northwest at apdanw@apdaparkinson.org or call 206-695-2905.

Financial Hardship Fund Application
Applicant Information

"Applicant" is the person diagnosed with Parkinson's disease or Parkinsonism.
Applicant Name*

First NameLast Name
Applicant Address*

Street Address

Street Address Line 2

CityState

Zip Code
Applicant Email*
example@example.com
Applicant Phone Number*
Please enter a valid phone number.
Applicant Phone Number is:*

MobileHome
Applicant Year of Diagnosis*
Applicant Year of Birth*
Have you received a financial award from APDA in the last twelve (12) months?*

YesNo
Please indicate the date of the last APDA financial award you received.*

MonthDayYear
Date
How do you intend to use these funds?*
Please provide a brief description of how you intend to use these funds.
Who should be the primary contact?*

ApplicantA Care Partner

Care Partner Information
Care Partner Name

First NameLast Name
Care Partner Relationship to Applicant
Care Partner Email
example@example.com
Care Partner Phone Number
Please enter a valid phone number.
Care Partner Phone Number is

MobileHome

Applicant Consent
I understand and agree to the following (must check each box):*

To the guidelines and requirements and request financial assistance from APDA.That these funds are intended to support people with PD who are experiencing a financial hardship and is not intended as an ongoing support fund.That the applicant/care partner is solely responsible for choosing how these funds are intended to be used and APDA assumes no additional responsibility.
Release of Liability: On behalf of myself, my heirs, successors, and assigns, I hereby forever release, indemnify, and hold the APDA, its officers, directors, employees, and agents, harmless from and against all injuries, deaths, claims, liabilities, losses, damages, costs, and expenses arising from or in any way related to, my participation in this fund. I intend this release to be effective, regardless of whether the claim of liability is asserted in negligence, strict liability in tort, or other theory of recovery.

The applicant and, if applicable, a care partner (or someone legally authorized to sign on his/her behalf) must sign, indicating their agreement with the guidelines and requirements mentioned above.

Signature: The signature(s) below indicate that I(we) have read and understand the eligibility and terms outlined in this application and confirm that the applicant is diagnosed with Parkinson's disease or Parkinsonism.
Applicant's Signature*

Clear
Please sign or put your initials.
Care Partner or Person filling out this form other than the Applicant

Clear
Please sign or put your initials.
Today's Date*

MonthDayYear
Date
Should be Empty:

APDA's mission: Every day, we provide support, education, and research to help everyone impacted by Parkinson's disease live life to the fullest.

Eligibility Guidelines

Financial Hardship Fund Application

Care Partner Information

Applicant Consent