CareLink Caregiver Support Grant Form Click Here to Learn About THis Grant "*" indicates required fields Step 1 of 2 50% Caregiver Information(unpaid family/friend caregiver)Caregiver Full Name* First Last Caregiver Address*Caregiver City*Caregiver State*Caregiver Zip*Caregiver Phone*Caregiver Email* Caregiver DOB*Caregiver SSN*Caregiver Gender Identity Male Female Gender Identity:Caregiver Ethnicity* Hispanic or Latino Not Hispanic or Latino Caregiver Marital Status* Widowed Married Divorced Single Caregiver Race* White Black/African American American Indian Asian Hispanic Other Do you live in a rural area?* Yes No Do you live alone?* Yes No Caregiver Relationship to patient*Hours of care you provide daily*How did you hear about this grant*Gross monthly household income* Care Recipient (Patient) InformationCare Recipient Full Name* First Last Care Recipient Physical Address*Care Recipient City*Care Recipient State*Care Recipient Zip*Care Recipient Phone*Care Recipient Email*Care Recipient DOB*Care Recipient SSN*Care Recipient Age*Care Recipient Gender Identity Male Female Gender Identity:Care Recipient Ethnicity* Hispanic or Latino Not Hispanic or Latino Care Recipient Marital Status* Widowed Married Divorced Single Care Recipient Race* White Black/African American American Indian Asian Hispanic Other Does the patient live in a rural area?* Yes No Does the patient live alone?* Yes No Diagnosis*Primary Speaking Language*County Care Recipient Resides In*For what kind of assistance are you applying?* In-Home Care Adult Daycare Short-Term Facility Stay Your privacy is important to us, please visit ALZark.org/grants to view our full privacy statement. Are there any individuals, other than you, with whom we may share grant information?Signature of Patient/Patient's Designated Respresentative*Date*Acceptance Signature of Caregiver*Date* 70927
