Stinson Neurology Foundation Grant Application
Please answer the following questions to see if you qualify for our grant.
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Patient's Name  *
Patient's Date of Birth *
MM
/
DD
/
YYYY
Address *
Phone Number *
Email *
Diagnosis *
Primary Care Doctor *
Neurologist
 *
Name of Primary Caregiver
 *
Relationship to Patient
 *
Date of Birth *
MM
/
DD
/
YYYY
Address (if different from the client)
 *
Phone (if different from the client)
 *
Email (if different from the client)
 *
Number of hours per week providing direct care
 *
Number of hours per week providing indirect care
 *
Support received by additional caregivers 
 *
List names or organizations, phone numbers, and amount of assistance they provide per week/month
 *
Please provide names and phone numbers of extended family/friends that might help in the future.
Annual Household Income
 *
Number of dependents living in the household 
 *

Please write an essay describing the patient's needs, how the caregiver helps, the challenges associated, and how this grant would benefit the client and the caregiver if chosen. 
 *
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