Go, Gus. Go! Holiday Grant Application

First name

Last name

Email

Phone

Birthday

Month

Day

Year

Address

Relationship to Individual with Special Needs:

Name and Age of Individual with Special Needs:

Diagnosis of Loved One with Special Needs:

Is your household currently experiencing financial hardship?

Yes

No

Yearly household income:

<$20,000

$20,000-40,000

$40,000-60,000

>$60,000

Amount preferred if chosen as a grant recipient:

$250

$500

$1000

Any amount will help our family

If chosen as a grant recipient, does the foundation have permission to use photograph of loved one with special needs on website and media platforms:

Yes

No

In a short summary, please explain what it would mean to your family to be a grant recipient as well as what the funds would be used for:

Please upload a recent photo of loved one with special needs:

**Applicant and loved one with special needs must reside in Michigan. Priority will be given to applicants residing in Bay County and experiencing financial hardship.

Go, Gus. Go! Holiday Grant Application

Registered Charity Number : 93-1703691