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Alzheimer's Arkansas

Caring for Caregivers

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Family Assistance Program Grant Form

"*" 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) Information

Patient 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 for?*

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?*

Receive Updates

Email*
First Name*
Last Name*
In which Arkansas County do you live?*

By submitting this form, you are consenting to receive marketing emails from: Alzheimer’s Arkansas, 201 Markham Center Drive, Little Rock, AR, 72205, http://www.alzark.org/. You can revoke your consent to receive emails at any time by using the SafeUnsubscribe® link, found at the bottom of every email. Emails are serviced by Constant Contact.

Text to Donate

alzark to 44321

Give Lively is our authorized platform for giving.

Address:

201 Markham Center Drive
Little Rock, AR 72205

Email: [email protected]

Hours: M-F 8:30am – 4:30pm
Phone: 501-224-0021
Fax: 501-227-6303

For immediate caregiver assistance after hours, call our Caregiver Line at 800-689-6090.

EIN: 71-0590114

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