GRASP Participant Request Form

* Name of Individual Requesting Funds:

* Phone Number of Individual:

* County:

* Date of Birth:

* Email of Individual

* Please provide a detailed statement about circumstances and need for funding.

* Have you ever received funding from GRASP?

* Do you have a job?

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

* What Home are you interested in?

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

* Where are you coming from?

Name of home group and sponsor

* Name of person filling out form: (Your name)

**Funds will NOT be approved for past due rent**

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