Working to enhance the lives of children and families living with Osteogenesis Imperfecta.
The Bennett Clayton Foundation Personal Health Grant
The Bennett Clayton Foundation Personal Health Grant is a quarterly grant of up to $2,500.00 funded by the Bennett Clayton Foundation for Children with OI. The Bennett Clayton Foundation Personal Health Grant will be issued to patients who have been diagnosed with Osteogenesis Imperfecta in accordance with the following guidelines.
dental intervention (due to OI)
wheelchair/walker/crutches (or other mobility aides)
hearing aids (due to OI)
any other needs not met by personal resources.
All funds received will be sent directly to health care provider or company from which services and/or items have been provided. Itemized receipts must be provided and verified for direct personal payments to be made. Direct personal payments will be made at the complete discretion of the BCF Board of Directors.
All grant designations will be made exclusively by the BCF Board of Directors. Funds will be granted based on financial need.
Bennett Clayton Foundation for Children with OI Personal Health Grant Application
Child’s Name_____________________________________ Child’s Age________
Child’s Gender ___________
Parent/Guardian Name _____________________________________________
City _______________________________ Zip Code ____________
Phone ( ) ______-__________
Primary Care Physician Name ___________________________________________
Primary Care Physician Address _________________________________________
Primary Care Physician Phone ( ) ______-__________
Orthopedist Name (if applicable) __________________________________________
Orthopedist Phone _____________________________________________________
Amount of funds requested: $______________________
Use of grant funds (include name and address of health service provider to which funds will be distributed): _______________________________________________________________
Semi-annual deadlines for applications: March 31, June 30, September 30 and December 31. Grants will be awarded within thirty(30) days of those deadlines.
Award determinations will be made exclusively by the Foundation Board of Directors.
I declare that recipient is not a “disqualified person” as:
1) I am not a substantial contributor of the Foundation (i.e. have not contributed an aggregate of more than $5,000.00 to the BCF).
2) I am not an owner of more than 20% of:
a) the total combined voting power of a corporation
b) the profits interest of a partnership
c) the beneficial interest of a trust or unincorporated enterprise
if the corporation, partnership, trust or enterprise is a “substantial contributor” to the Foundation.
3) I am not a manager of this Foundation.
4) I am not a family member of any individual described in 1, 2 or 3 above.
5) I am not a corporation, partnership, trust or estate in which persons described in 1, 2, 3 or 4 above own more than 35% of the total combined voting power, profits interests, or benefits interests, respectively.
6) I am not a government official.
The BCF will not approve grants to a disqualified person as defined in Internal Revenue Code 4946(a)(1).
I declare that all information provided herein is true to the best of my knowledge.
All information provided will be used only by the Bennett Clayton Foundation in the application review process and kept completely confidential.
Return to: Bennett Clayton Foundation, 36910 County Road 15, St. Peter, MN 56082