Crisis Micro Grant Application | The FitzLane Project

Apply for Crisis Assistance Micro Grants

Questions for General Information

These questions are used to obtain basic information about the individual applying for assistance. If you are a guardian applying for assistance for a child, please also provide your name and contact information in the free form area.

Preferred Name

Pronouns

Zip Code

Birthday

Preferred method of communication?

Phone Call

Text Message

E-mail

Last Name

Phone

Do you identify as part of the LGBTQIA+ community?

Yes

Not Sure

If so, how do you identify as part of the LGBTQIA+ community? (ex. Gay, Straight, Bisexual, Transgender, Non-Binary, Questioning, etc.)

Why are you seeking a crisis micro grant from from The FitzLane Project?

Use this area to provide any other beneficial information. This includes the name and contact info from a current psychologist if you are requestin assistance to see that individual. If you do not have a psychologist, you will be setup with Dr. Dani Rosenkrantz.

Legal Guardian Information

If the individual seeking assistance is under the age of 18, please provide the following information.

Legal Guardian First Name

Legal Guardian Last Name

Legal Guardian E-mail Address

Legal Guardian Phone Number

Legal Guardian Relation to Individual Seeking Assistance

Trusted Adult Information

If the individual seeking assistance is under the age of 18, and does not have legal guardian support during this time, please provide the below information. This will assist The FitzLane Project in their ability to provide monetary funding to the most at risk youth. Trusted adult individuals can include family members, teachers, school counselors, etc.

Trusted Adult First Name

Trusted Adult Last Name

Trusted Adult E-mail Address

Trusted Adult Phone Number

Trusted Adult Relation to Individual Seeking Assistance

Demographic Questions

These questions are completely optional and do not have any impact on your ability to be approved for LGBTQIA+ specialized therapeutic funding. They are solely used for metrics to gauge the impact our organization is having within our community.

Congratulations on taking the steps to become your most authentic self! Someone from The FitzLane Project will be in touch with you within 2 business days.