Collective Care Fund Application
[Update: Third Root Community Health Care closed for good in December of 2021 -- we are leaving this form here in the hopes that future Healing Justice businesses take on the work of extending free and low cost Collective Care to our communities]  

Building on the models of "Collective-Self" care and Healing Justice (Ortega-Williams, 2020), Third Root launches our Collective Care fund to provide health services to the most impacted members of our community.

Through the generosity of our supporters, we are able to provide low to no cost care where it’s needed most - to Black, Indigenous People of Color, prioritizing local Flatbush residents,  trans women and femmes, and disabled and formerly incarcerated community members.

**Due to the changes of Key to NYC, we are able to provide in person services such as Massage, Acupuncture, and Thai Bodywork to vaccinated community members only.  If you are unvaccinated we can provide virtual herbal consultation, and virtual yoga classes via the Collective Care Fund**

We are additionally awarding care from the Em Samolewicz Healing Fund, a scholarship for Trans women and femmes of any race in memory of Em - who was a long term Third Root volunteer, staff member and advocate for Trans women’s health.  

To apply please complete this application.   Applications will be accepted until this seasons fund is dispersed, and services can be used until Third Root's closure December 19, 2021.
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First & Last Name *
Email *
Phone *
Street Address *
Pronouns *
RACE/ Ethnicity
Do you Identify as
Were you formerly incarcerated? *
If YES - do you currently need legal advocacy? *
Are you disabled? *
Are you an immigrant? *
Are you a community organizer / activist? *
Are you an intergenerational Brooklyn resident? *
Current Annual Income *
Do you support other people financially? If so, for how many people are you the major financial support? *
Are you UNEMPLOYED? *
Are you UNDER EMPLOYED? *
Do you receive any of the following public benefits?  Medicaid, medicare, SNAP, cash assistance *
Required
I am interested in accessing LOW COST virtual yoga classes at Third Root.  
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I am most likely to benefit from & use these services  in the next 3  months: *
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Are there other services you would like to access at Third Root to support your health?
Do you have any current issues affecting your health?
Are you currently or were you recently impacted by any of the following?
Are you currently or were you recently impacted by any of the following?
Are you currently or were you recently impacted by any of the following?
Are you a senior citizen
Are there other aspects of your health that you'd like to make sure we're aware of?
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