CARE GRANTS

Our Care Grants will support direct patient care. Please select the target(s) your application will focus on. Select all that apply:

Patients with a household income at or below 300% of the Federal Poverty Guideline.

Patients with a HDHP, are underinsured or not insured.

Patients 0-26 years old with little family support and/or insurance; marginalized adults.

Patients engaged in a high-cost treatment service (i.e., TMS).

Organization Name

Address

Phone

Email Address

Contact Person

Title

Contact Person Phone

Contact Person Email Address

Profit or nonprofit organization

Profit

Nonprofit

Purpose of organization (include mission statement and goals)

Year Incorporated

Tax ID

Current Sources of funding

Approximate annual income of organization

Grant request amount

Main purpose of funding request

Describe how funds would be used if awarded

What criteria does your organization use to determine financial hardship?

Requirements

Within one year of receipt, provide a detailed report on the grant’s use with testimonials of its impact.
Provide a “Final” detailed report of the grant’s use before requesting additional funding.
Partner with us by prominently displaying LightMHK’s logo in your business and mentioning the LightMHK grant in publications.

I hereby state that the information given herein is true and correct. I authorize any required verification bureau report. I understand that if this information is determined to be false or deceptive, I and/or my organization will be liable for repayment of grant funding. I understand that this request for financial assistance may not pertain to health care other than mental health.

I agree

E-signature Responsible Party Signature

By signing this form electronically, and clicking on “Submit Signature”, you are agreeing to the terms stated herein.