Apply for Assistance Zip CodeSelect Asisstant *Do You Want 1 Time AssistantDo You Want Continous AssistantPersonal InformationNameDate of BirthCurrent residential addressPhoneEmail AddressGovernment-issued identificationChoose FileNo file chosenDelete uploaded fileCitizenship statusHome healthcare needs What type of home healthcare assistance do you need?Senior CareMental HealthHousing SolutionsInside Housing SolutionsHow often do you need assistance?DailyWeeklyHoursPart-timeFull-timePersonal StoryPlease share your personal story about why you are seeking this funding for home healthcare assistance.Other DocumentsProof of address: (Attach a utility bill or lease agreement)Choose FileNo file chosenDelete uploaded fileDocumentation of name changes: (If applicable)Choose FileNo file chosenDelete uploaded fileOptional InformationThe following sections are optional but encouraged. Providing this information may help us better understand your needs and circumstances, and may support reporting requirements for donors and grants. All information will be kept confidential.Personal StatementReferral SourceAdditional CommentsIn a few sentences, please describe your current situation and why you are seeking support from YC Foundation:How did you hear about YC Foundation?DoctorHospitalCommunity organizationSelf-referralIs there anything else you would like us to know that may support your application?ZipcodeSubmit
