Applicant information

First name

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Last name

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Phone

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Phone type
Email address

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Email type

Address

Address

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Apartment, suite, etc. (optional)
City

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Country/region

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State

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ZIP code

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Date of birth

Month

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Day

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Year

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Background

Gender

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Ethnicity

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Languages
A.

Patient With You Fund

Eligible patients may apply for the Patient Special Needs Fund once per calendar year. The maximum amount that can be awarded is $250.00

Special Needs Request

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If you chose Other please exlain

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Requested Amount

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What is the purpose of this request

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When do you need this grant?

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Have you ever applied for a grant from this fund before? If so, when and what was the result?

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Other comments/information that would be helpful in reviewing this application?

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B.

Patient Information

Please Complete ALL Sections

Branch Number

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Social Worker's Name

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Are you the patient applying for financial assistance?

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Date of Death (If Applicable)

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Is/was the patient a veteran?

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Location of Patient

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C.

Vendor Information Section

This is the information for who the money will be sent to. Please complete ALL sections

Name of Vendor

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Account or Reference Number

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Vendor Address

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Vendor Phone Number

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D.

Supporting Documents

Supporting documentation is required and must be submitted with the application. Examples of documentation include past due utility bills, police/fire reports, invoices of funeral expenses, quotes for equipment or services, bereavement camp registration documentation, etc. Incomplete requests will not be processed.

Do you have access to your supporting documentation to upload?

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If Yes, Attach Supporting Document

Description

Select a file to upload. Maximum size is 10MB.

I certify that the information provided in this grant application is true and correct to the best of my knowledge. The Carnation Foundation shall not obtain any information that would constitute "protected health information," as such term is defined in 45 CFR 160.103, from Agape Care Group, Inc., or their wholly owned subsidiary or affiliate or any group health plan sponsored by one of the aforementioned parties. Any intentional misrepresentation of the information contained in this application will result in forfeiting this and any future grant application. I authorize the Committee administering this program to verify any assets needed to process my grant application. Furthermore, I understand that any grant I receive from this program will be treated as taxable income.

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I understand that The Carnation Foundation Committee will take reasonable measures to protect my privacy. However, I understand that my anonymity cannot be guaranteed.

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I understand that funds may not be available at this time, and that my application does not guarantee approval of funds.

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Confirmation

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