Grant

Provider*	--None-- The Salvation Army SWCAA SWCAA
Grant Name*

Caregiver (Grandparent)

Caregiver First Name*
Caregiver Last Name*
Caregiver Gender*	--None-- Female Male Non-Binary Other
Caregiver Marital Status*	--None-- Married Widowed Divorced Separated Single
Caregiver Primary Language*	--None-- English Spanish Italian Polish French Chinese Creole Russian German Greek Hindi Vietnamese Urdu Albanian Korean Arabic Gujarathi Kru, Ibo, Yoruba Telegu Serbo-Croatian Bengali Ukrainian Japanese Mandarin Hungarian Tamil Turkish Patois American Sign Language Other Danish Cantonese Romanian Farsi Cambodian Portuguese Tactical Sign Language
Caregiver English Proficiency*	--None-- Proficient English Some English Limited English No English
Caregiver Date of Birth (MM/DD/YYYY) *
Caregiver Phone*
Caregiver Street*
Caregiver City*
Caregiver State/Province*
Caregiver Zip*
Caregiver Has Alzheimer’s Disease or a Related Dementia
Caregiver Ethnicity*	--None-- Hispanic/Latino Not Hispanic/Latino
Caregiver Race*	White Black/African American Asian Native American/Alaskan Native Native Hawaiian/Pacific Islander
Caregiver's Individual Income is About:	--None-- Under $1,255 (100%) $1,256 - $1,569 (125%) $1,570 - $1,883 (150%) $1,884 - $2,196 (175%) $2,197 - $2,510 (200%) $2,511 or over (over 200%)
Caregiver Lives With Their Spouse and Both of Their Income Is About:	--None-- Under $1,703 (100%) $1,704 - $2,129 (125%) $2,130 - $2,555 (150%) $2,556 - $2,981 (175%) $2,982 - $3,407 (200%) $3,408 or over (over 200%)
Caregiver Living Arrangements*	--None-- Alone With Spouse With Unmarried Partner With Spouse/Partner and Child/Children With Child, No Spouse With Grandchildren With Other Relatives With Others
Caregiver Housing*	--None-- Private Home Private Apartment Senior Housing Congregate Housing Public Housing Nursing Home Residential Care Home Assisted Living Other
Caregiver Needs Help With the Following Activities (select all that apply)	Eating Dressing Bathing/Washing Using Toilet Getting Out of Bed/Chair Continence
Caregiver Needs Help With the Following Activities (select all that apply)	Planning/Preparing Meals Shopping Managing Money Using Telephone Housekeeping Doing Laundry Taking Medicine Using Transportation

Grandchild

Grandchild First Name*
Grandchild Last Name*
Grandchild Gender	--None-- Male Female Non-binary Other
Caregivers Relationship to Grandchild*	--None-- Grandfather Grandmother Grandparent
Grandchild Date of Birth*
Grandchild Ethnicity*	--None-- Hispanic/Latino Not Hispanic/Latino
Grandchild Race*	White Black/African American Asian Native American/Alaskan Native Native Hawaiian/Pacific Islander Other
Grandchild Between Ages of 18-59 and Has A Disability*	--None-- Yes No

Additional Grandchild (If Needed)

Additional Grandchild First Name
Additional Grandchild Last Name
Additional Grandchild Gender	--None-- Male Female
Additional Relationship to Grandchild	--None-- Grandfather Grandmother Grandparent
Additional Grandchild Date of Birth (MM/DD/YYYY)
Additional Grandchild Ethnicity	--None-- Hispanic/Latino Not Hispanic/Latino
Additional Grandchild Race	White Black/African American Asian Native American/Alaskan Native Native Hawaiian/Pacific Islander Other
Additional Grandchild Between Ages of 18-59 and Has A Disability	--None-- Yes No

Confirm Form 5

Provider & Grant Name*
Additional Comments