PART I – Steward Referral Form.

This form should be completed by the person who works most closely with the candidate being referred. Once the form is submitted and we confirm eligibility for an award, you will receive a second form to be completed by your candidate. 

If you have any questions, please send them to claire.fay@thegah.org or call 202-437-4167.

Section A: Checklist for a Successful Referral
Below are the 10 key factors we consider in making awards. Please respond to each one.
1. My candidate is an adult (18+ years old). *
2. The one-time provision of the product or service recommended for my candidate substantially will enhance his/her wellness. *
4. To the best of my knowledge, my candidate has great financial need and no medical insurance or personal resources to accomplish what is recommended for his/her consition. *
Section B: The Condition and Recommendation
In this section, please provide information about your candidate and his/her condition and the recommendation for addressing it.
5. Regarding the cost of the product or service my candidate needs. *
Check all that apply.
Section C: Contact Information
Your name. *
Your name.
Your candidates name. *
Your candidates name.
Your telephone number. *
Your telephone number.
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Once you submit this form, you should hear back from us shortly, but in case you don't hear back within 2 or 3 days, please check in with a text to 202-437-4167.  

Thank you.