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ANTR Dementia Grant Application

The ANTR Board will review all applications on a weekly basis. They will be looking for key indicators such as: diagnosis, financial need, emotional need, and access to social support.

Please provide a full narrative of your caregiving experience and current situation. One sentence and one-word answers do not give the review committee a full understanding of your situation. Please provide as much detail as you can so that we can learn more about you and your loved one.

Once you submit your application, you will be contacted by email within 15 days with the review committee's decision. All applicants will be notified of their status via the email or phone used to register. Please add [email protected] to your contact list in order to receive your application status emails promptly. If you are not receiving our emails, please check your spam, junk or clutter folders.

Applicant Information

Full Name(*)

Please type your full name.

Full Address(*)

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E-mail(*)

Invalid email address.

Phone(*)

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Individual In Need

Individual's Full Name(*)

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Full Address(*)

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Individual's Date of Birth(*)

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If awarded a monetary grant, how would you choose to use these funds?(*)

DMERespite CareLight Home Modifications Invalid Input

How'd You Hear About Us(*)

ANTR Foundation EventCare Assistance ServiceFamily/ FriendFacebookGoogleOther Please specify your position in the company

Have you or your loved one received a grant from the ANTR Foundation in the past?(*)

Yes, I am a past grant recipient

No, I have never been awarded an ANTR Foundation Grant

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In order to support more families in need of respite care, the ANTR Care Grants guidelines are listed below. Any questions can be emailed directly to [email protected]

Grant awards will be limited to a maximum of THREE (3) awards per applicant within an 18-month period.
Of those three grant awards, there is a maximum limit of TWO (2) Extended Relief Grants.
Once the maximum number of grant awards is reached, the grant recipient will be eligible to reapply 18-months from the start of the first grant awarded.
Grant recipients will be notified via email when they are eligible to apply again.

Professional Diagnosis(*)

YesNo Invalid Input

Has your loved one been professionally diagnosed with Alzheimer’s disease or related dementia?

Type of Dementia Diagnosis(*)

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Date of Diagnosis(*)

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Diagnosis By(*)

PhysicianAlzheimer's Specific ProfessionalOther Invalid Input

Were you told what stage of Alzheimer’s disease your loved one has?(*)

YesNo Invalid Input

Is your loved one living in a traditional style home or apartment?(*)

Traditional HomeApartment Invalid Input

Do the live alone?(*)

YesNo Invalid Input

Do they live with family/caregiver?(*)

YesNo Invalid Input

Can your loved one be left alone?(*)

YesNo Invalid Input

Check all that apply:(*)

Agitation

Aggressive - Physical (scratches, spits, throws things, hits, bites)

Aggression - Verbal (refuses care, yells)

Anxiety

Delusions

Hallucinations

Paranoia/Suspicion/Accusations

Resistance to receiving help or care

Sleep Disorders

Sundowning (a state of confusion occurring in the late afternoon and spanning into the night)

Trouble Speaking/Conversing

Wandering

Yelling and Shouting

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Please explain any item that you checked in the above box(*)

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What ADLs are needed? (Check all that apply)(*)

Bathing

Grooming

Dressing

Toileting

Incontinence Care

Bedbound

Transferring

Ambulation(Walker/Wheelchair/Scooter)

Feeding Assistance

Meal Preparation

Stabilization

Medication Reminders

Transportation

Light Housekeeping

Falls in the last 6 months

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Please explain any item that you checked in the above box(*)

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Care Giver General Information

(The following questions are about the person living with Alzheimer’s or another dementia in your home. We collect demographic data to help us better understand who we are serving and how best to provide care.)

Please select the one statement that best describes your current care situation:(*)

I am the primary caregiver for my loved one and currently pay for support services to help, such as adult daycare, in-home care, or other services.

I am the sole caregiver for my loved one and live with my loved one and other friends and/or family.

I am the primary caregiver for my loved one, but have been awarded assistance locally, such as adult daycare, help at a community or religious center, or a government-sponsored program.

I am the sole caregiver for my loved one and live alone with my loved one.

I am the primary caregiver for my loved one and have help from other family members and/or friends that live outside the home.

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When did care start on a consistent basis? Tell us more about the care provided.(*)

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Are you caring for more than one person in addition to your loved on with Alzheimer's or Dementia?(*)

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Are you currently receiving assistance from Medicaid, Medicare, PACE or other Healthcare Assistance?(*)

YesNo Invalid Input

My monthly income is able to(*)

Cover most of my caregiver expenses

Cover some of my caregiving expenses

Not able to cover my caregiving expenses

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Caregiver Experience - Share Your Story

Please share with us your current caregiving experience and situation. Provide as much detail as you can so that we can learn more about you, your loved one, and how your life has been impacted?

How has this disease affected your loved one physically?(*)

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How has this disease affected your loved on emotionally?(*)

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What assistance does your loved one require with Activities of Daily Living?(*)

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Tell us about your daily routine and what challenges you face providing care.(*)

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How has providing care for your loved one with Alzheimer’s affected you as a caregiver physically, emotionally, and financially?(*)

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With what areas of your life do you think this grant would help the most?(*)

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How should we contact you?

E-mailPhone

When would you like to be contacted?(*)

Please select a date when we should contact you.

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ANTR Dementia Grant Application

Applicant Information

Individual In Need