Kindness with Care Application

Kindness with Care Application

Please complete the application below to apply for the Sam’s Caregiver Alliance Group’s Kindness with Care initiative.

"*" indicates required fields

Caregiver Info

Caregiver Name*
Caregiver Email*
Caregiver Address*
Do you live in the same household as the Care Recipient?*
Caregiver's Race*
Caregiver's Sex*
Caregiver's Age*

Care Recipient Info

Care Recipient Name*
MM slash DD slash YYYY

Items Needed

Please list what the funds will be used for.
If funds are to be used for nursing home expenses or household bills, please upload a copy of the billing statement of each expense.
Drop files here or
Max. file size: 100 MB, Max. files: 10.

    Signature

    Typing your full name below will constitute your legal signature.
    Please enter the date of your signature below.
    ** Sam’s Caregiver Alliance Group will provide one $100 payment per year for one Care recipient depending on the amount of donations collected and number of applicants.
    This field is for validation purposes and should be left unchanged.