Application for Assistance from the Alex’s Saints Foundation, Inc
Terms and Conditions:
The Alex’s Saints Foundation, Inc is organized and operated as an independent 501(c)(3) charity that provides life-changing financial and emotional assistance to young adults who struggle with substance use disorder, while empowering long term recovery. The Foundation was established in honor and memory of Alex St. Pierre from Troy, Michigan, who lost his battle with addiction on August 2, 2019. Visit our website at www.alexssaints.org for more information. The Alex’s Saints Foundation, Inc is primarily funded by contributions and support from Alex’s friends and family, business sponsors and caring members of the community.
Requests for financial assistance will be reviewed on a regular basis and all requests will be reviewed within 14 days of receipt. Applications should be completed and returned to info@alexssaints.org .
The Board of Directors, Officers, and Grant Committee collectively maintain all power, control and direction of the Foundation’s assets. All information provided to the Foundation shall be maintained in a confidential manner subject to the terms of this application and the Personal Media Release. If awarded a grant, you must agree to sign the Personal Media Release Form and will work cooperatively with the Foundation to develop an approved quote, personal testimony, photos, videos and/or images regarding you or your loved one’s story. This is necessary to grow awareness and help support the Foundation’s efforts to raise funds to help other individuals and families affected by this epidemic.
Eligibility: You are eligible to apply if you meet the following conditions:
You or your eligible family member is at least 17 years or older.
You or an eligible family member have experienced an event that qualifies for support under the Foundation’s Mission Statement. A qualifying event is defined as the following:
The need for substance abuse recovery treatment or counseling that is not covered by insurance and you or the eligible family member lacks the ability to pay for such services without jeopardizing the ability to cover your basic living expenses.
A death of an eligible family member, when loss of income, funeral expenses, or uninsured medical expenses affect your ability to cover basic living expenses due to the death of your loved one.
Family crisis (personal or financial hardship) brought on by a battle with addiction that affect your ability to cover basic living expenses.
Grants: Submitting an application for assistance does not guarantee a grant will be awarded. All applications are subject to available funds and the review, recommendation and approval of the Grant Committee and Board of Directors.
All grant checks will be sent directly to the vendor, creditor, or payee to cover eligible expenses for a specified bill or invoice.
Distributions will be made directly to the applicant only in unusual circumstances and as approved by the Grant Committee or Board of Directors.
Application: To be considered for grant support, please complete the following application. Incomplete applications will not be considered. Answering questions thoroughly will help us quickly process your request.
To provide an accurate and complete representation of your request for financial or emotional assistance, please attach all bills, invoices, estimates and other supporting documentation that you feel will aid the Grant Committee in making its decision.
Please also be prepared to provide additional documentation supporting your circumstances if requested by the Grant Committee.
Status : You will be notified of the status of your application by email.
1. Personal Information
Who is Filling Out this Application?:
Self
On Behalf of Recipient
First Name:
Middle Name:
Last Name:
Date of Birth:
Age:
Email (Will Receive Confirmation Email):
Cell Phone Number:
Home Address:
Current Employer:
Job Role:
Who is your current insurance provider?:
What is your approximate annual household income?:
Name Relationship and Phone Number of Reference:
2. Narcotic Usage
What narcotic has caused your Substance Use Disorder?:
How long have you been suffering from a Substance Use Disorder?:
Provide any further information describing your Substance Use Disorder:
3. Treatment Request
Preferred Treatment Center:
Addiction Treatment Services Sober Living
Archways Recovery
Brighton Center for Recovery
Dakoske Hall (ATS)
Dawn Farm
Guiding Light
Harbor Hall
Harbor Oaks
Henry Ford Maple Grove
Home of New Vision
Liberty House
Life Challenge Ministries
Meridian Health Services
New Hope Recovery Houses
Newport Academy
Oakland Family Services
Quality Behavioral Health
Sacred Heart Rehabilitation Center
Sanford Behavioral Health
Skywood Recovery
Timberline Knolls
Other (List Below)
Other Preferred Treatment Center:
What treatment programs will you be attending?:
How long will you be in treatment?:
How much financial assistance will you be needing for treatment?:
Please provide any further information regarding your treatment plan for the grant committee:
Attach a file of all bills invoices estimates and other supporting docs for the grant committee:
4. Consent / Conclusion
I Agree to the Above Terms and Conditions:
I Agree
I Do Not Agree
Other Way you Heard About Us:
Signature:
Today's Date:
Any last comments?: