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Applicant
Information |
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Name
of person who the grant is for |
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Please
enter: last name, first name |
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Doe,
John |
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Street
and Mailing Address |
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1
Verney Drive |
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City |
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Greenfiled |
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State/Province |
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NH |
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Zip/Postal
Code |
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03047 |
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Main
Phone |
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547-3311 |
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e-mail
address |
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hgf@crotchedmountain.org |
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Name
and contact information of case manager |
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If
applicant is served by a case manager, enter name,
organization and contact information of applicant's case
manager including phone number and e-mail address. |
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Mary
Helper
Helping Organization
1 Helper Way
Greenfield, NH 03047
555-1212
mhelper@helpingorganization.org |
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Age
of applicant and date of birth |
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Age:
10
DOB: 6/21/99
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Description
of disability |
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In
order to be eligible for Harry Gregg Foundation funds,
applicants must have a disability. |
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Cerebral
Palsy |
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Household
Information |
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Enter
number of adults in household |
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2 |
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Enter
number of minors in household (under age 21) |
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3 |
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Total
number of people in household |
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This
number must equal the total of household members listed
above. |
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5 |
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Income
Information |
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Please
review the funding and income guidelines section on the
web site to determine your income eligibility for Harry
Gregg Foundation funds. Verification may be requested.
If the applicant is a minor (until age 21) or claimed as
a dependent, the income of his or her parents must be
reported. If married, income of spouse must be included.
Please provide a breakdown of all sources of GROSS
monthly income as requested in the following questions.
If you do not receive income from a source listed,
please enter "none" in the box. |
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Monthly
GROSS income from all employment |
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$1500 |
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If
a two parent family, are both parents employed? |
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If
employed, please indicate if jobs are part time or full
time. |
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one
parent employed part time |
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Please
list your occupation(s) |
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sales |
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Monthly
unemployment benefits |
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none |
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Please
list monthly income from Worker's Compensation or other
disability insurance |
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none |
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Please
list monthly income from Social Security benefits |
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Include
all SS, SSI, SSD income for all family members |
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$1200
SS |
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Please
list monthly income from child support |
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none |
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Please
list monthly income from TANF |
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none |
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Please
list monthly subsidized housing/Section 8 benefit |
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none |
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Please
list monthly income from all other sources, ie,
pensions, rental income, etc. |
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none |
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Please
list your total MONTHLY GROSS income |
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This
number must match the total of income sources listed
above. |
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$2700 |
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| |
Contact
Information |
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Contact
Prefix |
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Name
of primary contact or person who should receive
correspondence regarding this request, ie, parent, case
manager or other person responsible for submission of
this application. |
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Ms |
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Contact
First Name |
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Jane |
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Contact
Last Name |
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Doe |
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Contact
title or relationship to applicant |
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mother |
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Contact
Phone |
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547-3311 |
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Contact
Phone Extension |
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Contact
Fax |
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Contact
E-mail |
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hgf@crotchedmountain.org |
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Proposal
Information |
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Request
Date |
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June
23, 2009 |
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Describe
the equipment, service or activity requested in this
application. |
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Please
review the project guidelines on this web site to be
certain your project is one that is funded by the Harry
Gregg Foundation. A written estimate must be uploaded
with all home modification requests. |
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adaptive
bicycle |
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Amount
you are requesting from the HGF |
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Harry
Gregg Foundation grants are limited to $1200, but are
rarely that much due to the number of requests we
receive. Requests can be no more than $1200. Recreation
grants are limited to $300. Recreation grant requests
cannot exceed $300. |
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$1000 |
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Other
available funds |
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Please
list all other funds available for this project and
sources including funds requested or pending from other
foundations or organizations, insurance,
Medicaid/Medicare contributions, applicant or applicant
family contribution, HCBC funds or other sources. If no
other funds are available please enter "none." |
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$500
request pending from First Hand Foundation
$200 Partners in Health |
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Project
Budget |
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|
List
the total cost of your project |
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$2400 |
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Request
Narrative |
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Please
write a short narrative describing the service,
equipment or activity you are requesting funds for, and
how it will help you. Please include any information you
feel would be helpful to the Trustees as they consider
your request. |
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John
wants so badly to play with his neighborhood friends on
their terms. A bicycle would certainly make that
possible while providing him with much needed
independence and confidence, as well developing core
strength and balance. |
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Attachments
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Title |
File
Name |
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Medical
Diagnosis |
clshist
boyd r.pdf |
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