Simple Heroes

Simple Heroes Grant Application

Date(Required)

Case Manager Name

Volunteer Name

Youth's Name(Required)

First Last

Requested Amount(Required)

Payment Recipient

CASA

Guardian

Vendor

Type of Request(Required)

Select All

Activity

Tangible Items

Services

check all that apply

Description of activity, item or service(Required)

Complete this section if payment recipient is a vendor

Name

Website

Phone Number

Mailing Address

Street Address Address Line 2 City State ZIP Code

We will mail your reimbursement

If the payment recipient is a CASA volunteer or guardian, complete this section. A reimbursement check will be mailed to you.

Name

First Name Last Name

Mailing Address

Street Address Address Line 2 City State ZIP Code

We will mail your reimbursement