Hope Grant

Hope Grant

In partnership, Hope Loves Company and Paint for A Cure are committed to bringing financial support to our ALS community for that may not be covered by insurance or other means. Our primary focus is on serving families who have minor children at home as we understand the unique challenges and financial impacts of the disease on young families. Our needs based grants are reviewed on a rolling basis and can be applied for proactively or in reimbursement form.
Applicant Information (Payment will only be made to person living with ALS)*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Applicant Email*
example@example.com
Applicant Phone *
Please enter a valid phone number.
Alternative Contact Person (if applicable, is there someone else we should communicate with as it relates to documentation and/or this request?)

First NameLast Name
Alternative Contact Phone Number
Please enter a valid phone number.
Alternative Contact Email
example@example.com
Please tell us about the household composition including number of people residing in home, children and their ages.*
I am requesting funding for:*

Reimbursement of a qualified expense I've already incurred.Payment in full for project/need that is qualified.Partial payment for a larger project that is qualified.
Amount Requested: *
Total Cost of Project/Need:*
If your request is less than the total cost of project/need, please share with us where the additional funding will come from/came from. (eg: if you are seeking support with bathroom modifications that will cost $20,000 and your request is for $6,000, please share with us additional funding sources to cover the project. Please list other commitments you have from organizations/grants.)
By signing this form, I agree to honor the standards below and attest that the information is true and accurate. *

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The Hope Grant assists families with expenses that are not typically covered by private insurance or other assistance programs and can be reimbursements or pre-paid expenses/support to families. The grant can cover, but is not limited to durable medical equiptment, home care assistance, travel costs related to an ALS diagnosis or research, home or auto modifications, computer access, communication devices, smart home technology, environmental controls, and generators.

Funding is limited and will be awarded on a first come, first serve basis however will be reviewed against total cost of project/need. (i.e if a home modification is needed, and total cost is $20,000, your request can be up to $6,000, but project will be evaluated based on how the remainder of project will be funded).

Documentation is always required. If you are asking for reimbursement, reciepts are required. If you are seeking pre-funding, quotes are required.

Respite Care

Allowed Expenses

Not-Allowed

Patient sitting services by anyone NOT living in home.

House cleaning, lawn/yard, snow removal.

MUST be performed at patients primary residence.

Residential living/room and board fees.

Caregiving provided by anyone living in the home.

Communication Needs (medically necessary)

Allowed Expenses

Not-Allowed

Communication devices which may include iPad or similar device, internet connection watches.

Augmentative communication devices.

Smart home and augmentative communication accessorires, softwares and apps.

Computer repairs.

Internet fees or phone bills.

Virus protectors

Home Modifications

Allowed Expenses

Not-Allowed

Material and labor for building of ramps or lifts.

Bathroom accessibility.

General home accessibility.

Smart home technology.

Interior or external painting.

Medical Expenses, Equiptment and Supplies

Allowed Expenses

Not Allowed

FDA approved medication for treating ALS.

Medical marijuana and card.

CBD products

Durable medical equiptment

ALS clinic fees.

PEG tube supplies

Bipap Supplies

Wheelchair upgrades and repairs.

AFO braces and splints

Beds and mattresses

Generators

Personal alert systems

Portable ramps

Patient focused counseling prescribed by a naurologist or general practioner.

Health insurance premiums.

Alternative therapies prescribed by a nrurologist or general practioner.

Toiletries that help with treatment of ALS.

Any over the counter prescription medications (with the exception of medications prescribed by a medical professional to treat symptoms of ALS)

Utility Bills (with the exception of catching up on arrears)

Non-ALS related doctor/hospital fees or co-payments (including dental or vision)

Transportation

Allowable Expenses

Not-Allowed

Mileage to/from an ALS Clinic, clinical study, ALS standard medical appointment and/or supportive programs for patient.

Rental of handicap accessible vehicle and/or car service.

Adaptations for vehicles to make them accessible.

Purchase of handicap accessible vehicle or maintanence of this vehicle.

Lodging for ALS Clinic appointments and/or travel for supportive programs.

Driving evaluation.

Mileage to/from pharmacy, dental, or any medical appointments not listed.

Purchase of vehicle that is NOT accessible.

Standards for reciepts/quotes that must be included with this form as attachments.

For services:  Recipets for reimbursement are needed. Quotes FROM PROVIDER must be attached.

For transportation:  If submitting for mileage, you MUST complete a mileage log and attach to this form. Gas reciepts are not accepted.

For items purchased:  Reciepts for reimbursement are needed. Invoices indicating payments have been made are needed to be attached to this form. WE cannot accept credit card statements, bank statements, or copies of cancelled checks.

If additional items need to be submitted, you can do so to grants@hopelovescompany.org
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