Safety Net Grant Program 2026

1. Click ‘Get Form’ to open the Safety Net Grant Program application in the editor.
2. Begin by filling in the Patient Name and Birth Date fields. Ensure accuracy as this information is crucial for eligibility.
3. Complete the Parent/Guardian section, including their agreement with program eligibility. This must be signed by a legal guardian.
4. In the Validation/Request for Support section, check appropriate boxes for assistance needed (Transportation, Medical Supplies, Medication, Co-Payment) and provide detailed descriptions of attached documents.
5. Fill out Household Financial Information accurately, including the number of people in the household and total annual income. Attach last year’s tax return as required.
6. Provide Recommending Healthcare Provider Information, ensuring that all details are filled out correctly and that the provider signs off on the application.
7. Finally, ensure that both the patient and guardian verify their signatures at the end of the application before submitting it via mail or email.

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