Harry Gregg Foundation Sample Online Application Applicant Information Name of person who the grant is for Please enter: last name, first name Doe, John Street and Mailing Address 1 Verney Drive City Greenfield State/Province NH Zip/Postal Code 03047 Main Phone 547-3311 e-mail address hgf@crotchedmountain.org Name and contact information of case manager 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. Mary Helper Helping Organization 1 Helper Way Greenfield, NH 03047 555-1212 mhelper@helpingorganization.org Age of applicant and date of birth Age: 10 DOB: 6/21/99 Description of disability In order to be eligible for Harry Gregg Foundation funds, applicants must have a disability. Cerebral Palsy Household Information Enter number of adults in household 2 Enter number of minors in household (under age 21) 3 Total number of people in household This number must equal the total of household members listed above. 5 Income Information 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. Monthly GROSS income from all employment $1500 If a two parent family, are both parents employed? If employed, please indicate if jobs are part time or full time. one parent employed part time Please list your occupation(s) sales Monthly unemployment benefits none Please list monthly income from Worker's Compensation or other disability insurance none Please list monthly income from Social Security benefits Include all SS, SSI, SSD income for all family members $1200 SS Please list monthly income from child support none Please list monthly income from TANF none Please list monthly subsidized housing/Section 8 benefit none Please list monthly income from all other sources, ie, pensions, rental income, etc. none Please list your total MONTHLY GROSS income This number must match the total of income sources listed above. $2700 Contact Information Contact Prefix 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. Ms Contact First Name Jane Contact Last Name Doe Contact title or relationship to applicant mother Contact Phone 547-3311 Contact Phone Extension Contact Fax Contact E-mail hgf@crotchedmountain.org Proposal Information Request Date June 23, 2009 Describe the equipment, service or activity requested in this application. 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. adaptive bicycle Amount you are requesting from the HGF 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. $1000 Other available funds 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." $500 request pending from First Hand Foundation $200 Partners in Health Project Budget List the total cost of your project $2400 Request Narrative 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. 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. Attachments Title Medical Diagnosis File Name clshist boyd r.pdf