Project/Patient Assistance Grant Application

2. Contact Information
In the event that the staff who submitted the grant request leaves the organization during the grant period, the Foundation needs the contact information for a second individual who is responsible for the project.
b. Address of Organization*
c. Address to send check if that differs from the organization’s address
3. Amount Requested: $8000 maximum for Chapter/Association/Other and Hemophilia and/or Sickle Cell Treatment Centers; $10,000 maximum for national organizations and the eight Federally-designated and funded regional core centers.
11. Itemized Budget and Budget Narrative - Format. SEE SAMPLE BUDGET IN APPENDIX D OF THE GRANT GUIDANCE. Budget: must be itemized with each item and amount including personnel names. Budget and narrative apply to HAF funds only.
Be sure to include required attachments specified in the Guidance.

Note: your uploaded documents MUST be in PDF, JPG, or JPEG format. THE APPLICATION MUST BE SUBMITTED ONLINE. ONCE COMPLETED, THE REPORT MUST BE SUBMITTED ELECTRONICALLY BY PRESSING THE “SUBMIT” BUTTON AT THE BOTTOM OF THIS FORM. YOU WILL RECEIVE AN ELECTRONIC CONFIRMATION OF RECEIPT.
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Acknowledgement*
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Note 1: After clicking the “Submit” button below, a notification email will be sent to the Primary Contact Person’s email address that includes a copy of your report in PDF format. The PDF will be attached to the email. Note 2: If, after submitting the form, you don’t receive a notification email in your Inbox, then please check your spam folder and whitelist the email address info@hemophiliaalliancefoundation.org. YOU ARE RESPONSIBLE FOR MAKING SURE YOU RECEIVE THIS ACKNOWLEDGEMENT OF RECEIPT.
Accepted file types: pdf, jpg, jpeg, Max. file size: 32 MB.
Accepted file types: pdf, jpg, jpeg, Max. file size: 32 MB.
Accepted file types: pdf, jpg, jpeg, Max. file size: 32 MB.
Accepted file types: pdf, jpg, jpeg, Max. file size: 32 MB.
This field is for validation purposes and should be left unchanged.