COVID-19 Rapid Response Grant Application

Date

Name

First Last

Phone

Email

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

What is your relationship with the Pascua Yaqui community?*

The Pascua Yaqui Tribe Charitable Organization was organized to provide assistance to the Pascua Yaqui communities in Arizona. Please indicate which community you are associated with and/or your relationship to the community.

Type of household*

Individual or household without minor children
Family/household with minor children

How many people living in household*

How many minor children living in the household*

If none, enter the number zero in the field.

In anyone in your household of Hispanic or Latinx origin?

Yes
No

Gender of the head of household*

Female
Male
Other or Non-binary
Prefer not to answer

How do members of this household describe their race? (check all that apply, for any member of the household)*

White
Black or African-American
American Indian or Alaska Native
Asian
Native Hawaiian or Pacific Islander
Other

Is anyone in the household age 65 or older?*

Yes
No

Is anyone in this household a veteran?*

Yes
No

Does anyone in this household have a disability or chronic health condition?*

Yes
No
N/A

Amount requested*

Please provide the amount requested, and be willing to provide evidence, such as invoice from the funeral home, Eviction Notice from landlord, COVID-19 positive test result, etc.

Evidence of COVID-19 Impact

Drop files here or

Please provide evidence to support your request. Acceptable forms of evidence may include: an invoice from the funeral home, Eviction Notice from landlord, COVID-19 positive test result, etc, Notice of layoff from employer, etc.

Request Type*

Eviction Relief
Funerary Expenses
Laptop grant

Please describe the request and why it is needed*

Please provide as much detail here as possible.

Tell your story*

Tell the story: Describe the household, their needs, and how these funds and your services will assist them. Please be advised that United Way may use these stories in public communications. Identifying information, such as name or place of employment, will be removed if stories are shared. If you have any photos to share, please email them to director@yaquicharity.org

COVID-19 Rapid Relief Funding

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