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Application For Assistance

Personal Information

This information is required by the foundation based on its charter with the IRS. All Information will be held in strictest confidence and will not be shared with any public or private entity. The foundation reserves the right to ask for documentation of any of the below listed financial information.

*The Joseph S Groh Foundation does not provide cash as a means of assistance. Assistance is provided in the form of payment for materials or services needed by the applicant, and payment is made directly to the supplier. The foundation reserves the right to seek additional information before making a decision about a request. This information will typically be sought either by email or phone.

*Name of Applicant: This field is required.

Applicant's Address

*Address:

*City:

*State/Province:

*Postal Code:

*Phone Number: Enter a valid phone number.

*Email address: Enter a valid email address.

*Describe Your Career in the Construction Trades Industry: This field is required.

*Describe in Some Detail Nature of Disability: This field is required.

*Please Describe How and When Disability Occurred: This field is required.

*Describe Where You Learned about Our Foundation: This field is required.

*Type Of Assistance Desired: Please help us understand the type of assistance you are looking for in terms of equipment (i.e. home & bath remodel, Hoyer lift, wheelchair van, assistive technology, rehabilitative equipment etc.): This field is required.

*Please List the Dollar Amount of Requested Assistance: This field is required.

*Name of Potential Providers: This field is required.

*Phone Number of Potential Providers: Enter a valid phone number.

*Financial Information* Please describe what impact this disability has had on your financial situation: This field is required.

*Please describe what insurance coverage you have relative to this disability: This field is required.

*Please describe any other benefits you are receiving for this disability, including SSDI or a private disability policy: This field is required.

*Are you working with any other charities regarding possible assistance, and if so, what types of assistance might they provide?: This field is required.

*Please describe how you anticipate the funding of this request will change or improve your situation? What will it allow you to do that you cannot do now?: This field is required.

*Our foundation is very small, and unfortunately we have more grant requests than we can fund. Please tell us what is unique about your situation, needs or circumstance that would cause our board to fund it over some other compelling requests?: This field is required.

Submit

By submitting, you agree to receive text message communication from us per our Terms and Conditions and Privacy Policy, which state that we will never share your personal information or spam you.

The Joseph S. Groh Foundation is dedicated to providing financial support and guidance to people with a connection to the plumbing, electrical, roofing, construction, or HVAC industries who are living with life-altering disabilities.

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