Grant Application — Bridge the Gap Fund

Applicant information

Applicant name*

Relationship to individual*

Individual's name (if different)

Individual's date of birth*

City / county of residence*

Email address*

Phone number*

Select all that apply.

Other diagnosis — please describe(optional)

Optional — upload documentation

PDF, DOC, or image. Optional — you may share documentation later by email.

What service are you requesting funding for? Select all that apply.

Other service — please describe(optional)

Provider name*

Provider contact information*

Total cost of service*

Amount requested ($2,500 max)*

Briefly describe your financial situation and why this support is needed at this time*

Have you pursued funding from any of the following?

How will receiving this support make a difference?*

When is the service expected to begin?*

Is this:

UrgentWithin 3 monthsFlexible

Signature (type your full name)*

Date*

By submitting, you confirm the information above is complete and accurate to the best of your knowledge.