Rotary Club of PearlandCommunity Impact Grant Program
Individual / Family Assistance Application
Applicant Information
To ensure timely consideration of your request, all application questions must be answered completely and all required documents must be submitted. Incomplete applications may not be processed.
Name:
*
First Name
Last Name
Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number:
*
Format: (000) 000-0000.
Email Address:
*
example@example.com
How long have you lived at your current address?
*
Less than 6 months
6 months–1 year
1–5 years
More than 5 years
Household Information
Has documentation confirming your current local residency been included?
*
Yes
No
Number of Adults in Household:
*
Number of Children in Household and Ages:
*
Annual Household Income:
*
Marital Status of Applicant:
*
Single
Married
Divorced
Widowed
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Employment Information
Number of working adults in the household:
*
None
One
Two
More than Two
Employment status of primary applicant:
*
Full-Time
Part-Time
Self-Employed
Unemployed
Unable to Work
Retired
In the last 12 months, has your household experienced any of the following?
*
Loss of employment
Reduction in work hours
Unexpected medical expenses
Housing instability
Caring for a family member
Increased childcare expenses
Death in immediate family
Which statement best describes your household currently?
*
We are financially stable and planning ahead
We are managing but have limited flexibility
Unexpected expenses create financial stress
We are struggling to meet monthly obligations
We are currently in crisis or emergency conditions
Urgency & Timing
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How urgent is your request?
*
Immediate emergency (needed within 7 days)
Urgent need (needed within 30 days)
Important but can wait 1-3 months
Long-term planning need
What may happen if assistance is delayed?
*
Request Information
Type of Assistance Requested:
*
Medical / Adaptive Equipment
Accessibility Improvements
Educational Assistance
Emergency Hardship Assistance
Transportation Assistance
Youth Program Support
Other
Total Cost of Expense:
*
Amount Requested from the Community Impact Grant:
*
Personal Contribution Available:
*
What specific expense(s) will the requested funds be used for?
*
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Upload supporting documents
*
Upload a File
Drag and drop files here
Choose a file
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Supporting Documentation
Which supporting documents are you providing?
*
Medical bill
Utility bill
Rent notice
Repair estimate
Program invoice
Insurance denial
Employer separation notice
Other supporting documentation
Other Assistance Sources
Have you applied for assistance for this same need from any other source?
*
Yes
No
If yes: Organization You Applied With:
Amount Requested:
Status of Your Application:
Pending
Approved
Denied
If You Were Approved, Amount Received:
Rotary Connection
Was this application referred by, sponsored by, or discussed with a member of the Rotary Club of Pearland?
*
Yes
No
If yes, please provide the member's name:
First Name
Last Name
I certify that the information provided is true and accurate, that grant funds will be used only for the purposes described in this application, and that supporting documentation may be requested at any time.
Signature
*
Printed Name
*
First Name
Last Name
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Preview PDF
Submit
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