Grant Application

	Grant Application Grants made from proceeds of the Ventilator 5K events sponsored by the ARCF provide funding for patient education and care. Grants to groups may be used to sponsor speakers, purchase supplies, pay to rent meeting facilities, or other activities that provide a benefit to the public in the area of respiratory care. SSL Certificates Grants to individuals may be used to provide medication, treatment, supplies, accommodations for living, or other expenses relating to patients with a primary diagnosis of a respiratory disease. All fields marked with are required*

	Requester Information
	*First Name:
	*Last Name:
	*Company/Organization:
	*Street Address:

	*City:
	*State/Province:
	*Zip/Postal Code:

	Recipient Information
	For Individuals
	Individuals: Grant must be used to provide medically necessary items or care and include a statement of necessity by a licensed health-care provider.
	*First Name:
	*Last Name:
	*Street Address:

	*City:
	*State/Province:
	*Zip/Postal Code:
	*Phone:
	*Email:
	*Has this person applied for a grant in the current year (maximum annual grant is $500)?		No Yes

	For Groups
	Organizations: Grant must be used for public education relating to pulmonary diseases or research support of projects relating to pulmonary diseases.
	*Group Name:
	*Executive Director’s (or equivalent’s) Title:
	*Group Type (non-profit, community, etc):
	Tax exempt EIN:
	*Business Address:

	*City:
	*State/Province:
	*Zip/Postal Code:
	*Business Phone:
	*Email:
	*Has this group applied for a grant in the current year (maximum annual grant is $1000)?		No Yes

	Request Information
	*How will the funds be used?
	*What is the expected outcome?


	*Amount Requested:
	Date of Event (if applicable):