Financial Support Program

Financial Support Program
APDA’s mission: Every day, we provide the support, education, and research that will help everyone impacted by Parkinson’s disease live life to the fullest.

APDA Rhode Island Chapter is pleased to offer a Financial Support Program that provides financial assistance to people with Parkinson’s disease (PD) and their families. Approved applicants will be granted up to $400, once per calendar year (January – December) Funds are limited and will be awarded on a first come basis. Funds may be used for programs, services and/or activities designed to improve quality of life.
Instructions:
Applications are reviewed on a rolling basis and applicants will be notified within sixty (60) days of receipt. These scholarships are awarded on a first come basis and are based on availability of funds. The program is subject to change or discontinuation with limited notice.

Eligibility Guidelines:

To qualify for this Financial Support Program, the applicant will:
- Complete and submit the entire application
- Attest to having a diagnosis of Parkinson's disease or Parkisonism.
- Understand the program is intended to support persons with Parkinson's disease in need of financial assistance.
- Reside within the APDA RI Chapter area.
- Reside in the community, not in a rehabilitation center or long-term care, skilled nursing facility.
For information about Parkinson’s disease, information and referrals to services in the community, events and volunteer opportunities or general questions, please contact 401-439-8435 or email apdari@apdaparkinson.org
Applicant and Care Partner Information
(“Applicant” has a diagnosis of Parkinson’s disease or Parkinsonism)
Total Amount Requested:*
(up to a $400 one-time payment per calendar year (January-December) can be awarded)
This scholarship is intended to be used for the following program(s) (check all that apply):*

Exercise/WellnessAdaptive EquipmentRespite/Adult Day ProgramAssistance at HomeOther
Applicant Full Name:*
Address:*
City:*
State:*
Zip Code:*
Phone*
Email:
example@example.com
To better understand the people we serve, please provide the following information about the Applicant
Year of birth
Year of Diagnosis
Care Partner Full Name (if applicable):
Care Partner Relationship to Applicant:
Care Partner Phone
Care Partner Email
example@example.com
Have you applied for this scholarship or any other related financial award from APDA in previous years

YesNo
Applicant Consent
Client Consent: I understand and agree (please check each box):

To the guidelines & requirements of this program & request financial assistance from APDA.That the applicant/care partner is solely responsible for choosing the provider for the programs this scholarship is intended to be used for and that APDA assumes no responsibility for choice of provider.That any additional expenses beyond the approved amount will be the applicant’s sole responsibilityTo provide copies of receipts/invoices to APDA for the purpose this scholarship was intended to be used.
Release of Liability: On behalf of myself, my heirs, successors, and assigns, I hereby forever release, indemnify, and hold the APDA, its officers, directors, employees, and agents, harmless from and against any and all injuries, deaths, claims, liabilities, losses, damages, costs, and expenses arising from or in any way related to, my participation in this program. I intend this release to be effective, regardless of whether the claim of liability is asserted in negligence, strict liability in tort, or other theory of recovery.

The applicant and, if applicable, a care partner (or someone who is legally authorized to sign on his/her behalf) must sign or make some mark indicating their agreement of the guidelines and requirements as mentioned above.
Applicant's Signature*

Clear
Date*

MonthDayYear
Care Partner Signature (if applicable)

Clear
Date

MonthDayYear
Should be Empty:

Financial Support Program

Instructions:

Applicant and Care Partner Information

Applicant Consent