ALR Grant

Agency Name

Agency Mailing Address

City

State

Zip

Year Agency Was Established

Which best describes your agency (Select One):

Non-profit Organization
Faith-Based Organization
Local (City/County) Agency
State Agency

EIN:

Name of Person Submitting Grant Application:

Title

Email Address

Phone Number (with Area Code):

Program Name

Grant Purpose

Startup
Expansion

Target Populations (Select All That Apply):

Rural Communities
Medically Underserved Communities
Low-Income/Limited Resource Caregivers
Veterans

Service Focus (Select All That Apply)

Alzheimer’s Disease and Related Dementias
Autism Spectrum Disorder and/or Sensory Processing Disorder
ID/DD (Down syndrome, CP, etc.)
Physical Disabilities/Medically Fragile
Mental Health

Is this program open to all members of the community regardless of race, religion, or political affiliation?

Yes
No

Which Alabama counties are served by this program?

Is there currently a waitlist for this respite program? If yes, how many caregivers are on the waitlist?

What is the fee (if any) for this respite program?

How many full-time, unpaid family caregivers receive respite through this program annually?

How many hours of direct respite service does this program provide annually?

Program Description: Provide an overview of your services.

Fund Utilization: Specifically, how will this grant increase the number of people served or the quality of care provided to the target populations?

for of Year

Amount Requested:

Line-Item Budget

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Attach a breakdown of expenses (Staff, Supplies, Rent, etc.).

If issued grant funds, the organization will be required to provide a report by Jan. 31, 2027, describing grant outcomes. Photographs and/or short videos are encouraged with this report. Submission of such information implies permission for Alabama Lifespan Respite to use online and in reporting. Is your organization willing to comply with this requirement?

Yes
No

Supplemental Materials (Optional)

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Attach brochures, letters of support, or program calendars.