Caregiver Grant Application

Apply for a Road Scholar Caregiver Grant
Application Type

Caregiver Grant
Personal Information
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email Address*
example@example.com
Where did you learn about the Road Scholar Caregiver Grant program?*
Information of Person for Whom You Provide Care
Name*

First NameLast Name
Relationship*
Nature of illness or disability*
How long have you been this person's caregiver?
Living Situation

My loved one lives/d with me.My loved one lives/d at a different address.
Program Information

Please provide the following information about the program for which you want to register (pending availability):
Program Name*
Please choose a program that takes place in the U.S. or Canada.
Program Number*
Program Date*

MonthDayYear
Enter the program start date listed in print or on our website.
Double or Single Occupancy*

Double OccupancySingle Occupancy
Deposit Amount*
Please note the deposit amount can vary by program. See the program page for required deposit amount.
Total Program Cost (Up to $2,500)*
Please note that the prices published on the web and in print vary by date and by single or double occupancy. The total program price for your specific date and rooming selection must be $2,500 or less. No exceptions can be made.
Caregiving Expenses/Detail Information
The Road Scholar Caregiver Grant is financial assistance to attend a Road Scholar educational adventure. Please provide details of your caregiving expenses that help demonstrate your need for financial aid.

If you are arranging substitute care for the time that you will be on the program, please list, detail and provide the estimated cost of substitute caregiver arrangements necessary and attach copies of relevant documentation (i.e. hourly respite care services or the cost of an airline ticket for another family member to fly to your home to provide substitute care).

Otherwise, please list, detail and provide the estimated monthly expenses that your household incurs (or incurred) for your loved one i.e. skilled and unskilled care; co-payments; home modifications; etc. and attach copies of relevant documentation.

You may also upload your most recent tax return to demonstrate financial need.
Please provide information about your caregiving expenses.*
Attach File(s)

Limited to 2 files max. Accepted formats: Pdf, doc, and docx.
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Personal Statement
The purpose of the personal statement is to help determine why Road Scholar should award you a Caregiver Grant. Please tell us, in specific detail, why you want to learn with Road Scholar and how the experience would impact you as a caregiver. Please include any special circumstances or personal experiences that have influenced your program selection and/or your request for financial aid. This essay is used to help us determine need. When funds are limited, the personal statement can be the deciding factor between one application or another.
Note: 250-500 words are required.*

0/500
Tell Us About Yourself
Are you:*

MarriedWidowedDivorced or separatedSingle, never marriedPrefer not to answer
Gender*

FemaleMalePrefer not to answer
Race*

American Indian or Alaska NativeAsianBlack or African AmericanPacific Islander or Native HawaiianWhitePrefer not to answerOther
Ethnicity

Hispanic or LatinoNot Hispanic or LatinoPrefer not to answer
Please indicate your highest level of educational achievement (select one):*

Some High SchoolHigh School DiplomaSome College/UniversityAssociates DegreeCollege/University degreeMaster’s or Professional degreeDoctoral degreeOther
Employment Status:*

Employed Full-TimeEmployed Part-TimeSelf-employedDisabledHomemakerRetiredPrefer not to answerOther
If employed, please tell us in what profession/occupation; if retired, please tell us your last profession/occupation:*
Please describe any employment changes related to your caregiving duties.
Terms and Conditions
Please read "The Basics: What You Need to Know About Caregiver Grants" listed here.

By signing this application, you are agreeing to abide by the terms and conditions of the Caregiver Grant program; to allow Road Scholar to use your personal statement and thank-you letter in reporting to our donors (and the public at large) how donations to Road Scholar are being used; and to be identified in those materials by your first name, last initial, city and state (e.g. Mary S., Omaha, Nebraska).

Your financial and contact information will always remain completely confidential.

Please digitally sign this application by entering your full name and the date below.
Signature*
Please enter your name
Date*

MonthDayYear
Date
Please use this checklist to ensure that you are submitting all of the information required for the Caregiver Grant Committee to review your application.

After you hit the Submit button, you will see a confirmation page. If you do not see the confirmation, there is an error with your submission. Please scroll down the page to view the field(s) that need attention.

Incomplete applications will not be reviewed.
Checklist:

Verify your eligibility to receive a Caregiver Grant under the terms and conditions.Verify that your program selection is $2,500 or less and eligible under the terms and conditions.Verify that the date of your selected program is at least 8+ weeks away and that the final payment date has not yet passed.Complete all of your contact information.Fill out the Caregiver Expense/Detail sections.Provide the name, number and date of the program you have selected.Complete the 250-500 word personal statement.Sign and date the application.
Should be Empty:

Apply for a Road Scholar Caregiver Grant

Personal Information

Information of Person for Whom You Provide Care

Program Information

Caregiving Expenses/Detail Information

Personal Statement

Tell Us About Yourself

Terms and Conditions

Please digitally sign this application by entering your full name and the date below.