Apply for Assistance – Jim "Catfish" Hunter ALS Foundation

This grant application is intended to assist persons living with ALS (PALS) and/ or caregivers providing for PALS. The grant is intended to help with medical expenses, medical equipment, respite care, travel, or other needs PALS may have.

Grant Application Process

Please fill out the complete application. Once the application is received, you will receive notification of receipt. It will be reviewed by the Foundation’s Board of Directors. Please allow 1 month for review and approval.
Possible Grant uses may include, but are not limited to:
- Medical/ Pharmaceutical Expenses
- Home Health Assistance
- Travel Costs
- Home and Auto Modifications
- Medical Equipment/ Supplies
Funding of all grants will be based on need and available resources. If the full amount cannot be funded, the Foundation will work with the patient and caregiver to assist in the best way possible.
IMPORTANT:
Please enclose documentation for your request. This can be copies of invoices or paid receipts. This documentation should be emailed to applications@catfishfoundation.org. Please include your full name and any details pertaining to the documentation.
Using the online form below will directly submit the application for review upon receipt of documentation. You may also email/mail the application by filling out the PDF/DOC version linked below the online version of the application.

First Name *

Last Name *

Physical Address *

Mailing Address (optional)

If different than Physical Address

Phone Number *

Email *

ALS Clinic Name *

Neurologist Name *

Date of Diagnosis *

Date of Birth *

Grant Amount Requested *

Please round to the nearest value.

What will this grant funding be used for? *

Primary Caregiver Information

Please enter the information below for the primary caregiver.

Caregiver First Name *

Caregiver Last Name *

Caregiver Physical Address *

Caregiver Mailing Address (optional)

If different than Physical Address.

Caregiver Phone Number *

Caregiver Email *

Relationship to Patient *

Validation *

I understand that Foundation grants are intended for use by those who truly need financial assistance. To the best of my knowledge and belief, the information I provided above is true, correct, and complete.

Comment

To email/mail your application please click a link below.

Please make sure your application is signed and dated when submitted.

You can email this application to applications@catfishfoundation.org
– or-
Mail the Application to the Foundation at:
The Jim “Catfish” Hunter ALS Foundation
PO Box 47
Hertford, NC 27944

Questions or Comments? Please contact us!