Mary Gale Flex Fund Application

The Mary Gale Flex Fund is to be used for a short-term service or item that has not been funded by any other sources or services. Priority is given for critical/emergency needs for the purpose of maintaining the health, safety and independence of older adults in New Hampshire. NOTE: This fund is restricted to low-income women ages 65 and older living in the greater Manchester community.

REQUESTING AGENCY INFORMATION

Entity Name

Select from the entities listed. If it is not listed, select the Other option. NOTE: If you have selected "Other" on a previous form submission, the entity name has been added to the list.

Name of contact submitting application

Email address for contact submitting application

Agency Contact Phone

Phone

Check if you would like to be contacted about new programs and services as they become available.

RECIPIENT INFORMATION

Recipient's First Name

Recipient's Last Name

Has the recipient received support from Easterseals in the past?

Yes

Unknown

Recipient's Address

Please enter full address (street, city/town, state and zip code). Proof of address may be required.

Recipient's Phone Number

Phone

Recipient's Date of Birth

Recipient must be at least 65 years old to qualify for funds.

Country of Origin

Immigrant, refugee or veteran status

Select all that apply from drop-down list.

What services does the recipient currently receive?

Select all that apply.

EXPLANATION OF NEED

Provide more detail on purpose or need for funds

To your knowledge, will this item or service prevent any of the following?

FUNDING REQUEST DETAILS

Complete the remainder of the form and submit for review by fund administrators. The agency contact listed above will be notified of approval or if additional information is required.

Amount of purchase/requested funds:

Enter amount in numeric format (i.e. 125.50)

How should the requested funds be provided?

Send me a copy of my responses

Report Abuse