"*" indicates required fields Step 1 of 2 50% Is applicant a US Citizen or non-US Citizen with Lawful Immigration Status or Permanent Resident?* Yes No Is applicant age 18-20?* Yes No In which county does the applicant reside?* Coffey County, Kansas Lyon County, Kansas Osage County, Kansas Elsewhere Has applicant resided in the county continuously for a minimum of one year?* Yes No The applicant is not eligible. The applicant must be age 18-20, must be a US Citizen or lawful immigrant, and must currently reside in Coffey, Lyon, or Osage County Kansas and have done so continuously for no less than one year immediately prior to application. Return to Home PagePlease click Next to proceed to the application. Application for AssistanceIs this your first time applying for the Transitions Grant?* Yes No Referred by:*Applicant InformationLegal Name* First Last Last 4 digits of SSN*Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Date of Birth* Month Day Year Age*Sex*Daytime Phone*Applicant Email* If Jones Foundation needs to contact you, would you prefer:* Phone Email Parent or Legal Guardian contact information (if applicable)Parent or Legal Guardian Name First Last Relationship to ApplicantParent or Legal Guardian Address Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Daytime PhoneParent or Legal Guardian Email If Jones Foundation needs to contact you, would you prefer: Phone Email Please list medical personnel, school faculty/staff, CDDO service providers, etc. that Jones Foundation may contact to determine grant eligibility:*Please provide detailed information about use of previous year’s grant funds and progress made towards the stated goal(s):*Please state in detail your post-high school transition goal: *Please note, if you choose to reapply for subsequent years, we will inquire about how funds were utilized and ask applicant to share progress toward goal(s).*Please describe in detail how applicant plans to utilize funding: *Please note, if you choose to reapply for subsequent years, we will inquire about how funds were utilized and ask applicant to share progress toward goal(s).*AcknowledgementBy completing this form and signing below, I acknowledge and agree to the following statements: This form is an application only. Completing this form does NOT guarantee the receipt of a Jones Foundation Transitions grant. The Jones Foundation reviews each application to determine whether the qualifications and eligibility have been met. All information provided in this application and its supporting documentation is true and accurate to the best of my knowledge and belief. I am providing this information voluntarily. I understand that intentional misstatements or falsification of the information in the application will render me immediately ineligible for the Jone Foundation Transitions grant. I certify that the applicant named (i) is a United States citizen or non United States citizen with Lawful Immigration Status of Permanent Resident, (ii) is at least 18 and under the age of 21, (iii) resides in Coffey, Lyon, or Osage County and (iv) has continuously resided in Coffey, Lyon, or Osage County for no less than one year immediately prior to the date on this application. I will immediately inform the Jones Foundation if this information changes in any way. All information provided in this application and its supporting documentation may be reviewed by the Jones Foundation staff and its Board of Trustees. I authorize the review of the information provided herein, including any protected health information, by the Jones Foundation staff and its Board of Trustees to determine eligibility for the Transitions grant. I authorize the Jones Foundation staff to contact those certain providers or individuals named in this application to verify or supplement the information provided in the application or supporting documentation. I agree to take on any liability related to KanCare, disability, etc. and will not in any way hold the Jones Foundation liable to potential consequences. Signature of Applicant or Legal Guardian*Date*
