PALS GRANT PROGRAM APPLICATION

PALS Information

Name(Required)

First Last

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Date of diagnosis(Required)

Phone(Required)

Email(Required)

Is the applicant a veteran?(Required)

Yes

Is the applicant registered with the ALS Association?(Required)

Yes

Relevant diagnosis(Required)

ALS

PLS

Other

Date of diagnosis(Required)

Proof of Diagnosis.(Required)

This does not have to be an official letter. You can submit any documents from your doctor, appointments, or hospital visits, that verify your diagnosis. Our team will reach out to your healthcare physicians listed if any further questions are required.

Drop files here or

Max. file size: 256 MB.

PALS Household Information

How many members of the household are there?

Person 1

Name

First Last

Relationship

Caregiver?

Yes

Over 18?

Yes

Person 2

Name

First Last

Relationship

Caregiver?

Yes

Over 18?

Yes

Person 3

Name

First Last

Relationship

Caregiver?

Yes

Over 18?

Yes

Person 4

Name

First Last

Relationship

Caregiver?

Yes

Over 18?

Yes

Person 5

Name

First Last

Relationship

Caregiver?

Yes

Over 18?

Yes

PALS Health Insurance Coverage Information

Type of Insurance(Required)

Private Insurance Provider(Required)

Additional Information about PALS health insurance coverage status:

PALS Medical Support Team Information

Consent(Required)

The following individuals have been informed of my intent to submit this grant application

A social worker has signed this application

By checking this box, I give permission to the Brigance Brigade Foundation to speak to the following individuals about details enclosed in this application

Primary Caregiver

Name

First Last

Phone

Organization / Relationship

Caregiver's Birthday

Physician / Nurse

Name

First Last

Phone

Organization / Relationship

Social Worker

Name

First Last

Phone

Organization / Relationship

Other (i.e. child, parent)

Name

First Last

Phone

Organization / Relationship

Financial Impact

Please describe current or predicted impact of ALS on your financial status (i.e. employment status, impact of COVID-19, etc.)(Required)

Have you applied for financial assistance from other organizations? If so, please list and indicate if awarded.

PALS Health Status

Mobility(Required)

Please Select One:

Independent

Assisted by cane/walker

Assisted by wheelchair

Other

Additional comments about PALS' mobility status

Communication(Required)

Please select all that apply

Speaks

Uses partner assisted communication (letter board, blinking, writing, etc.)

Assisted by smartphone or tablet

Uses speech generating device

Additional comments about how PALS' communicates:

Breathing(Required)

Please Select One:

Breathes independently

Uses CPAP, BiPAP or other non-invasive breathing machine

Uses ventilator or other invasive breathing machine

Additional comments about PALS' breathing status:

Activites of Daily Life (ADLs)(Required)

Please Select One:

Completes ADLs independently

Requires some assistance to complete ADLs

Requires total assistance to complete ADLs

Additional comments about PALS' ADLs:

PALS Grant support category request worksheet

*please check one box to reflect your greatest need, if mixing and matching multiple support categories. We encourage applicants to share more information about this choice in the open-ended questions below.

Caregiver respite or In-home healthcare

BBF is eager to consider support requests up to $5,000 to grant recipients for caregiver respite or in-home healthcare from an independent contractor or care agency, not covered by insurance. We encourage applicants to share more information about this choice in the open-ended questions below.

Greatest Need

Yes

How and/or what will you use this grant for?

Funding request(Required)

Proposed care plan including approximately how many hours per week care will be utilized(Required)

Required documentation to attach to application

Drop files here or

Max. file size: 256 MB.

Selection of care agency or independent contractor(Required)

Required documentation to attach to application

Drop files here or

Max. file size: 256 MB.

Quote for hourly rate from care agency or independent contractor(Required)

Required documentation to attach to application

Drop files here or

Max. file size: 256 MB.

Equipment & supplies

BBF is eager to consider support requests up to $5,000 to grant recipients for prescribed equipment purchase or rental from an equipment vendor, not covered by insurance. This includes equipment installation, supplies, and maintenance plans for equipment that assists PALS with mobility, communication, and breathing.

Greatest Need

Yes

How and/or what will you use this grant for?

Funding request(Required)

Quote from an equipment vendor(Required)

Required documentation to attach to application

Drop files here or

Max. file size: 256 MB.

In-home accessibility

BBF is eager to consider support requests up to $5,000 to grant recipients for in-home accessibility completed by a licensed contractor.

Greatest Need

Yes

How and/or what will you use this grant for?

Funding request(Required)

Quote from contractor(Required)

Required documentation to attach to application

Drop files here or

Max. file size: 256 MB.

Total:

Please note: PALS grant applicants may mix and match support categories, for a total grant request up to $5,000

Required documentation to attach to application(Required)

I have attached required documentation from each applicable support category

Open-ended questions for PALS

Thank you for including BBF as a part of your personal journey. We wish to celebrate your life by sharing more stories from those who have been touched by ALS as we build a sustainable future for the Brigance Brigade Foundation. Please answer questions as completely as possible to give us a wholistic view of applicants’ experiences. The information shared in this section may be utilized in BBF communications materials to PALS, CALS, donors and advocates.

Tell us about yourself

We recognize that you are more than your diagnosis. We want to hear about what makes you, you. Feel free to use the following questions as inspiration. What is your family like? What hobbies have you enjoyed throughout your life? What is your professional experience? What is your educational experience? What are you passionate about?

Why would a BBF PALS Grant be meaningful to you?

Please elaborate on how/why a BBF PALS Grant would be meaningful to you. Why did you select specific the support categories in your application? How will receiving a grant for in-home care, equipment, or home accessibility help you and your support team thrive with purpose and passion?

What is your ALS story?

Feel free to use the following questions help to tell your story, if needed. What were the immediate days after your diagnosis like? How did you share this news with loved ones? How did your family and friends respond? What has been most challenging for you? What inspires you?

Open-ended questions for Caregivers of people living with ALS (CALS)

Thank you for including BBF as a part of your personal journey. We recognize that ALS is a devastating illness to both people living with ALS and their caregivers. We value the time you’ve taken to share more about the backgrounds, experiences, and viewpoints of CALS. The information shared in this section may utilized in BBF communications materials to PALS, CALS, donors and advocates.

Tell us about yourself

We want to hear about what makes you, you. Feel free to use the following questions as inspiration for articulating who you are. What is your family like? What hobbies have you enjoyed throughout your life? What is your professional experience? What is your educational experience? What are you passionate about? How do you know your PALS? What is your relationship like? Share a favorite memory of your PALS.

How has being a caregiver changed your life?

Feel free to use the following questions to help tell your story, if needed. What was the most surprising thing you’ve learned about life with ALS? What scares you? What inspires you? How has your community supported you? In what ways would you like your community so support you more? What is your favorite form of self-care?

What programs do you hope to see from BBF in the future?

Have you been able to participate in any of our Chanda’s Caregiver Corner programing? We are continually looking to elevate and evolve our programs to better meet the needs of PALS and CALS. We’d like your input as we develop new programs. What challenges has ALS presented that you’ve struggled to address? What services would help you in your everyday life? What items on your daily to-do-list seem to consistently be left uncompleted?

Is there anything else that you’d like to share with us?

How did you hear about the Brigance Brigade Foundation PALS Grant Program?

Photo Submission

We require all applicants to include at least one photograph with their application. This can be a recent selfie, a family photo, a photo from a special occasion (wedding, graduation, birthday, etc.) or any photo that you feel supports the story you’ve told in the open-ended questions. We prefer that these photos are the highest quality image as possible. The BBF PALS Grant Committee is also delighted to accept optional supplemental materials to aid in sharing your story. Should you choose to submit a short video, it can help our Grant Committee understand your story in your own words. This is not required, but an optional format for you to share your life and journey with the PALS Grant Committee.

Photo(Required)

Drop files here or

Max. file size: 256 MB.

Signature of patient or patient representative

Date

Signature of social worker

Date