Working to enhance the lives of children and families living with Osteogenesis Imperfecta.


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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.

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 _____________________________________________

Address_________________________________________________________

City _______________________________  Zip Code ____________

Phone (       ) ______-__________

Email ___________________________________________________

 

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.

Parent/Guardian Signature___________________________________

Date ___________________

 

Return to:  Bennett Clayton Foundation, 36910 County Road 15, St. Peter, MN  56082