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Gray Area Project Grant Request Form
First name(s)
*
Last name(s)
*
Email address
*
Phone number
*
City and state of residence
*
This program is only able to support residents of the US.
Which best describes your situation?
*
A
Undiagnosed
B
Underdiagnosed
C
Medically complex
D
Chronically ill
E
Still searching for answers
F
Other
What care-access cost are you requesting help with?
*
A
Specialist visit
B
Diagnostic testing
C
Transportation
D
Medical records
E
Copay
F
Care-related supplies
G
Other
How much are you requesting?
*
If "other," it must be under $1,000.
A
$500
B
$750
C
$1,000
D
Other
If we are not able to fund the full amount requested, would a smaller grant still help?
*
A
Yes
B
No
C
Maybe
Have you received funds from Gray Area before?
*
A
Yes
B
No
Are you a member of Gray Area, or a family member or close associate of a member of Gray Area?
*
A
Yes
B
No
This program is intended to support individuals and families experiencing financial hardship. Tell us a bit more about the cause of your hardship, what bills you need to pay, and about the difficulty of your current financial situation.
*
Minimum 250 characters.
How would this grant help you take the next step toward care or answers?
*
Minimum 250 characters.
Please tick the box below to confirm that this financial hardship means you cannot meet your basic needs, that these funds will go toward a care-related need, and that you do not have the independent financial means to weather this hardship.
*
I confirm.
Optional: additional comments/feedback.
I attest that all information included here is true and accurate to the best of my knowledge.
*
Signature
Submit