1. Date of Application:
2. Caregiver Contact Information (Full name, address, phone number):
3. Caregiver Email:
4. Full name, age and relationship of the person you care for:
5. Describe the mental health condition of the person you care for and the details of how you care for them. Include how long you have been caregiving:
6. Explain in detail your need for support (examples: assistance with living expenses, medication, doctors, respite, transportation, self-care).
7. Explain your lack of financial resources (examples: your income solely supports your loved one, job loss, no insurance, unexpected emergency expenses).
8. Please provide a copy of some form of identification such as your drivers license, state ID, student ID, etc.
9. How did you learn about AMCF? Be specific and provide name of organization, doctor, support group, social worker, internet search, Facebook, etc.
10. Do you have any relationship with an employee or board member of AMCF? If yes, be specific and include first and last names:
11. AMCF collects demographic data for grant reporting only. Please provide your race, gender identity, and language spoken at home:
12. How many people live in your household?
13. What is your range of income? Select one:
A) Under $30,000 B) $30,000-$90,000 C) Over $90,000
MAIL APPLICATION TO:
AGNES MCCARTHY CHARITABLE FOUNDATION
300 CARLSBAD VILLAGE DRIVE
SUITE 108A – 167
CARLSBAD, CA 92008