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*