Apply for Help

Full Name

Address (Must be in Macomb or Oakland County, Michigan)

Phone

Diabetes Diagnosis

Type 1 Diabetes

Type 2 Diabetes

Diagnosed by (Physician Name or Facility)

Year of Diagnosis

Urgent Need: What do you need help paying for? (Check all that apply)

Urgent Need: If you selected Other, please describe here

Estimated cost of what you need:

Have you tried any other assistance programs? If yes, explain briefly.

Statement of Need: In 3-5 sentences, describe your situation and why you're applying for this grant.

Documentation: Include: proof of diabetes diagnosis and (if available) income hardship.

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I certify that the above information is true and accurate to the best of my knowledge. I understand that this grant is reviewed individually and may be awarded multiple times if needed, based on available funding. I understand I must complete a new application for each new request.

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