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Primary Grant Recipient Application Form
Name
Email
Full Address
Birth Date
Phone Number
Employer
Ethnicity
Relationship to child
Brother
Sister
Parent
Guardian
Aunt/Uncle
Family Friend
Co-Worker
Other
Permission from the family to refer?
Yes
No
Name
Email
Full Address
Birth Date
Phone Number
Employer
Ethnicity
Relationship to child
Brother
Sister
Parent
Guardian
Aunt/Uncle
Family Friend
Co-Worker
Other
Permission from the family to refer?
Yes
No
Name
Child's Age
Birthday
Medical Diagnosis
Date Diagnosis Made
Has Your Doctor Approved You Taking On This Responsibility?
Yes
No
Diagnosis Status
Active
Remission
Please Tell Us Your Story, In Your Own Words, So We Can Understand More About Your Journey
Are you looking to form a business (LLC, Corp.) or a Nonprofit (501c3)?
Form a Business
Form a Non-Profit
Planned name of business or nonprofit
Mission of business or nonprofit
Description of products or services you will offer
Who are you hoping your business or nonprofit will help?
Description of how this business or nonprofit will positively impact your community
How do you plan to fund your initial operations?
Please describe what your startup expenses include
What are your estimated total startup expenses, minus legal fees?
Anything else you’d like to share?
I understand, acknowledge, and agree that I am at least 18 years of age, have authorization to disclose this information, the information is accurate and truthful, and I am willingly and knowingly sharing sensitive medical information. I agree that if I am awarded a grant, Boss BeCause may share my/the grant recipient’s story, the fact that the recipient received a grant, and other information shared by me to support and further its charitable endeavors. I understand that grants are awarded on a case-by-case basis and there is no guarantee that I/the child specified in the application will receive a grant. I further acknowledge and understand that if my/the recipient’s receipt of a grant poses a conflict of interest, I/the recipient may be disqualified. I attest that by my electronic signature, below, I agree to the terms and conditions contained in this Grant Application.
I agree
I hereby forever discharge and release Boss BeCause Inc., now and in the future, from producing, utilizing, distributing, or otherwise exploiting any photos, videos, or recordings of me. I acknowledge and agree that my image or likeness may be used by Boss BeCause Inc. in promotional materials, advertising materials, program materials, or for other purposes, and that I will not be compensated or given additional opportunity to review and approve this material ahead of time.
I agree
Electronic Signature
Todays Date
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