Berks County Community Foundation-Moeller Fund

Margaret B. Moeller Memorial Fund for Alzheimer's Home Care Companions Application
The Margaret B. Moeller Fund for Alzheimer's Home Care Companions provides financial assistance to families with members who suffer from Alzheimer's disease or other forms of dementia for the purpose of obtaining the services of an in-home care companion, aide or other provider of respite care. Preference is given to families residing in the Boyertown Area School District, as that district existed on January 1, 2005. The fund is designed to assist families who are not eligible for any other form of reimbursement for such services. Grants generally pay for several days of care for a specified period of time.

Grant requests are reviewed in May and November annually.

Please complete the following information and click submit.

In addition to submitting this form electronically, please mail in one of the following items:

A copy of the receipt for in-home care that was not reimbursed in any other way; or

A copy of a quote for in-home care services that you would like to recieve

Mail to
The Margaret B. Moeller Memorial Fund
Berks County Community Foundation
P.O. Box 212
Reading, PA 19603-0212

Caregiver's Name:

Prefix	First	MI	Last	Suffix

Street Address:

Address 2 (optional):

City:

State: Zip Code: County

Phone Number (xxx xxx-xxxx):

Email address:

Patient's Name:

Patient's Address:

Patient's School District:

Caregiver's relationship to patient:

Patient's diagnosis and brief history of illness:

Type of assistance requested:

Amount of assistance requested:

Patient's insurance company:

Type of insurance coverage:

If there is someone other than the caregiver who should be contacted if we have questions about this application please list that person's name, email address and phone number below.