GRASP Participant Request Form

* Name of Individual Requesting Funds:

* Phone Number of Individual:

* County:

* Date of Birth:

* Email of Individual

* What recovery home are they interested in:

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

* Have you ever received funding from GRASP?

* Does this individual have a job?

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

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

* Where is this individual coming from?

Name of individual's home group and sponsor

* 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.