Individual Grant

Applicants must complete all questions on the application in order to be considered for a Joe Jackson Foundation Individual Grant, including providing contact info & estimates from at least 3 companies/contractors/suppliers for the equipment or renovations requested in the application. Incomplete applications will not be considered.

NO PHONE CALLS PLEASE. Due to the volume of grant applications, we respectfully request no phone calls or emails inquiring about the status of applications. Grant recipients will be notified by phone or mail upon approval.

Name*
First Last
Address*
Street Address Address Line 2 City State ZIP Code
Daytime Phone*
Alternate Phone
Date of Birth*
MM slash DD slash YYYY
Social Security Number*
Date of Injury*
MM slash DD slash YYYY
Level of Injury*
Cause of Injury*
How did you hear about us?*
Please describe the degree of your disability & how it affects you ever day?*
Please describe your sources of financial support (NOTE: grant recipients may be asked to provide supporting documentation)*
Please describe any other factors that you wish to be taken into consideration (health, living arrangements, financial concerns, family issues, etc)*
Please give a detailed description of the equipment or modification(s) for which you are applying, including manufacturer's name, model numbers, etc (if applicable)*
Please give a brief explanation of how the equipment or modification(s) for which you are applying would impact your daily life*
Additional Comments
Equipment Modifications Details
In order to be considered for the Joe Jackson Foundation Individual Grant, applicants MUST provide 3 estimates for the cost of equipment or renovations requested. Incomplete applications will not be considered.
Company 1
Company Name*
Contact Name
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone*
Website
Price Quoted*
Company 2
Company Name*
Contact Name
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone*
Website
Price Quoted*
Company 3
Company Name*
Contact Name
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Website
Phone*
Price Quoted*

Individual Grant

Equipment Modifications Details

Company 1

Company 2

Company 3