Grants

In order to protect the nonprofit status of the Gene Potts Memorial, if you have any personal familiarity with one or more individuals of the Board of Directors of the Gene Potts Memorial, we are unable to grant you an award due to your affiliation.

Additionally, applicants must reside in Texas and be currently undergoing radiation and/or chemotherapy treatment to be eligible for grant consideration.

Grant Timeline:

• Registration Opens: November 1st of 2024
• Application Deadline: December 31st of 2024
• Decision Announcement: January 13th of 2025

We appreciate your understanding and are here to support those who meet the criteria during their most challenging times.

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Basic Information

Contact Person *

First

Last

Phone *

Email *

Address *

Address Line 1

Address Line 2

City

AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

Zip Code

Medical Information

Diagnosis *

Date of Diagnosis *

Treating Physician

Name

Phone Number

Current Treatment Plan

Type of Treatment *

e.g. Chemotherapy, radiation

Treatment Center

Frequency and Duration of Treatment

Financial Information

Current Employment Status *Full-timePart-timeUnemployedRetired

Household Income

Other Sources of Income

Health Insurance StatusInsuredUninsuredRetired

Caregiver Information (If Applicable)

Caregiver's Full Name

First

Last

Caregiver's Relationship to Patient

Caregiver's Phone Number

Caregiver's Employment StatusFull-timePart-timeUnemployedRetired

Assistance Needed

Type of Assistance Requested *Financial Assistance for Medical BillsTransportation to TreatmentLodgingGroceries and EssentialsOther (Please Specify)

Paragraph Text

Description of Current Financial Challenges *

How Will the Grant Be Used? *

Additional Information

Have you received a grant from Gene Potts Memorial this year? *

• Yes
• No

Do You Have Any Other Sources of Financial Aid?

• Yes
• No

Have You Applied for or Received Aid from Other Organizations?

• Yes
• No

Describe your situation and how this grant will impact your life. *

How did you hear about us? *

Supporting Documentation (optional based on your criteria)

life. Gene how

Proof of Diagnosis

Click or drag a file to this area to upload.

e.g., letter from physician, medical records

Proof of Income

Click or drag a file to this area to upload.

e.g., tax returns, pay stubs

Proof of Residency *

Click or drag a file to this area to upload.

Health Insurance Documentation

Click or drag a file to this area to upload.

Consent to Share Information with Relevant Parties for Verification Purposes *

• Yes
• No

Signature *

Clear Signature

I do not have any personal or business relationships with any of the members of the Gene Potts Memorial Board of Directors

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