Family Grant Application

Step 1 of 4

Caregiver Information

To complete your application, please ensure that you provide all required information, including uploading your receipt or invoices. The application is incomplete without all the necessary information. All receipts should be dated within the past year.

Caregiver's Name

First

Last

How did you hear about the Family Grant Program?

Have you received funding from Autism Support of Alabama in the past 12 months?

If Yes, Please Explain

Mailing Address

Address Line 1

Address Line 2

City

State

Zip Code

Email ( Please make sure it is a correct active email address.)

Confirm Email

Phone

Your relationship to the person receiving care

Name of person receiving care

First

Last

Gender

Age

Does this person live in the home with you?

Please list this person's official diagnosis

Have you received a grant from Alabama Lifespan Respite in the past year?

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