Addiction Aid Network Standard Form

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Please complete this short form to begin the grant application process. Submitting this form does not mean you have been accepted; it simply allows us to safely collect your basic information. A team member will contact you by phone to learn more about your circumstances.

Name (first & last) *

Please enter your short name

Are you 18 or older? *

1. No

2. Yes

City and State where you CURRENTLY live *

Phone or email where we can text/send secure messages *

Submitting this form does not mean you have been accepted for a grant. This step simply allows us to collect your basic information safely. A team member will contact you by phone to discuss your circumstances further. Do you accept these terms? *

1. No

2. Yes

How soon do you need help? *

Which grant are you applying for? *

1. The Sandi Boswell Grant for Tattoo Repair

2. The Matt Fleming Grant for Trade Education

3. The John Lee Coats Grant for Sober Living

4. The Chris Alvarez Grant for Mental Health

Please put today’s date before submitting *

Submit

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