TILT APPLICATION FORM

"Quick Check Program" Application

*****VERY IMPORTANT: TO ENSURE YOUR APPLICATION REACHES TILT, LET US KNOW YOU JUST SUBMITTED TO US YOUR APPLICATION. TO DO THIS, GO TO OUR "CONTACT FORM" IN OUR MENU TO TELL US! (Not all your applications are reaching us. We are working on this problem.). Thanks for your understanding.

* Indicates required field

Organization's Name *

Applicant's Name *

First

Last

Applicant's Title *

Applicant's Email Address *

Supervisor's Name *

First

Last

Supervisor's Email Address *

Organization's Phone Number *

****Organization's COMPLETE MAILING Address -- Include BLDG & SUITE Numbers! *

Line 1

Line 2

City

State

Zip Code

Country

Patient's Life-Threatening Diagnosis *

SELECT whether Hospice Patient or Palliative Care Patient. *

PATIENT ID # [If Any] *

LIST the Item(s) or Service(s) to be Purchased. PLEASE BE SPECIFIC!! [EXCLUDE medical items, utilities, rent, mortgage, and funeral expenses] *

INCLUDE Website Link(s) for Desired Item(s)/Service(s) IF ANY. *

Anticipated Cost *

****STATE the Reason(s) WHY this Patient AND the Relatives CAN'T afford the Item(s)/Service(s). [What is their Living Situation? What is their Limited Source(s) of Income? Etc.] *

****EXPLAIN Why YOUR Organization is NOT paying for the Desired Item(s)/Service(s). *

Please CERTIFY to the following by check-marking each statement: *

Said item(s) and service(s) will be IMMEDIATELY PURCHASED with TILT's funds AND TIMELY DELIVERED to your patient. ALL the information in your application is TRUE and ACCURATE.

For TILT's Grant-Writing Use Only: *

Minority? Female? Male?

Applicant's Signature (Please Type) *

Date of Request *

Submit