Family Assistance Program 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 Gender* Male Female 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 Hours of care you provide daily*Relationship to patient*How did you hear about this grant?* Care Recipient (Patient) InformationPatient Full Name* First Last Patient Address*Patient City*Patient State*Patient Zip*Patient DOB*Patient Ethnicity* Hispanic or Latino Not Hispanic or Latino Patient Gender* Male Female Patient Race* White Black/African American American Indian Asian Hispanic Other Patient Marital Status* Widowed Married Single Divorced Does the patient live in a rural area* Yes No Does the patient live alone* Yes No Patient Diagnosis*For what kind of Assistance are you applying?* In-home Care Adult Daycare Short Term Facility Stay Homecare Supplies Home Modifications Legal Services Mental Health Couseling Utility Bill (gas, electric, water/sewage, garbage) Are there any individuals, other than you, with whom we may share grant information?*Signature of Caregiver*Date*Consent* The doctor’s diagnosis letter is mailed or faxed.*Consent* I agree and understand that by signing electronically, that all electronic signatures are the legal equivalent of my manual/handwritten signature and I consent to be legally bound to this agreement?* 78862
