Moved By Love Foundation Application - Opening Febmary 14, 2022 Caregiver Application FormPART I - Tell Us About YourselfCaregiver/Applicant:Name Address Telephone No Email Address Date of Birth Total Monthly Expenses:Rent/Mortgage Utilities Food Cable Insurance Others Do you own a car? - Yes/No -YesNoPlease answer the following questios:1-How long have you beena family caregiver? Please explain how you become a family caregive, why, and what type of challenges you've faced along the way. 2-Why are you seeking assistance and what type of assistance are you seeking? 3-Are you employed full time or part time? Tell us what ou do and for how long. 4-Are you being paid to be a caregiver? Tell us by whom and how much. 4-How did you hear about the Moved By Love Foundation? PART II - Tell Us About Your Family MembersFamily Member/Patlent:Name Telephone No Address Email Address Date of Birth Relationship to caregiver Medical Condition Medications Doctor Name Doctar Telephone No Doctor's Address PART III - DisclouserThe information contained in this application is for the purpose of obtaining assistance from the MOVED BY LOVE Foundation for the benefit of the undersigned (applicant). The application understands that the application will not be considered complete until all verification documents are submitted. The applicant understands that once the application is submitted, applicant will be contacted by a Representative for an interview and that process may take up to 30-60 days. The applicant understands that the information provided will be used in deciding whether to grant assistance and individually represents and warrants that the information provided is true and complete and that the MOVED BY LOVE Foundation may consider this statement as continuing to be true and correct. The applicant understands that the failure to provide accurate information and/or documentation or a material misstatement in this application will be enough to deny assistance from the MOVED BY LOVE Foundation. The MOVED BY LOVE Foundation is authorized to make all inquiries deemed necessary to verify the accuracy of the statements made on this application. The applicant grants to the MOVED BY LOVE Foundation the right to check any and all references with respect to the information contained in the application and the applicant waives any right to restrict the MOVED BY LOVE Foundation’s access to such information. Applicant understands that if such information is made unavailable to the MOVED BY LOVE Foundation, the MOVED BY LOVE Foundation may reject the application. All information will be kept confidential and will be used for the purposes intended. Applicant understands that the MOVED BY LOVE Foundation has the right to fully audit the use of the donation at any time. Applicant also understands that the MOVED BY LOVE Foundation may use this application, if approved, for publicity and promotional purposes. We may also use applicant’s name on our website but any additional use of the applicant’s name for promotional purposes will receive prior approval from the applicant.Submit OR Download Caregiver Application
