GRASP Emergency Funding Request Form for Individuals

* Name:

* Phone Number

* County of Residence:

* Date of Birth:

* Email:

* What recovery home are you interested in:

* Please provide a detailed statement about your circumstances and need for funding. (Be specific and detailed or your request will not be considered)

If you are already living in a recovery home, what date did you arrive:

* Have you ever received funding from GRASP?

* Where are you employed:

* Emergency Contact: (Please list name and number for a family member or close friend)

* Where were you previously residing?

Name of home group and sponsor

* Any additional information you'd like to share:

* Name of person filling out form:

By giving us your phone number and email address, you are giving GRASP permission to contact you via email, phone, or text.