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

Use of Funds

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.