Recovery Communication Fund Grant Application
Applicant Name *
Applicant Address *
Applicant Phone Number
County of residence (note this grant is currently only available in Hancock and Washington Counties)
Is it ok to leave a message at this number?
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If no number is available, please provide the best way to reach you
What are you requesting funds for?
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Person Completing this application
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Are you affected by Substance Use Disorder?
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Are you requesting funds for service, device or both? (This can include internet service) if you are not sure, please answer NA)
Do you currently have a Recovery Coach? *
If 'Yes' what is your coaches name?
Would you like more information about Recovery Coaching Services?
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If you are granted these funds, how will this connectivity help you in your recovery? *
Additional comments and/or instructions
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