GRASP Participant Enrollment Form

* Enrollment Date

* County:

* Name of House:

* Address of House that individual will be placed:

* Amount Requested: (Please put dollar amount requested and how long this will cover)

* Date of Birth:

* Name of Individual:

* Has this individual ever received funding from GRASP?

* Phone Numberof Individual:

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

* Where is this individual coming from?

* Email of Individual

* Please share the name of facility or location that the individual is coming from:

* Any additional information you'd like to share:

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

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