Be Well Circle · 501(c)(3)

Funding Application

Thank you for your interest in receiving support through Be Well Circle. All information is confidential and used only to determine eligibility for funding.

1 Applicant Information

Full Name *

Date of Birth *

Phone Number *

Email Address

Street Address *

City *

State *

ZIP Code *

Preferred Method of Contact

Phone Email Text

2 Household Information

Number of People in Household *

Number of Dependents

Are you currently employed? *

3 Annual Household Income

Total Annual Household Income (before taxes) *

If comfortable, estimated annual income

Do you have health insurance? Has your premium gone up?

4 Type of Support Requested

Please select the service(s) you are requesting assistance for *

Holistic Health Services (yoga, meditation, energy healing, holistic primary care, acupuncture) Educational Programs or Workshops Virtual Wellness Programs In-Person Classes Other (please describe below)

Name of Service Provider (if known)

Estimated Total Cost of Service/Program

Amount of Funding Requested *

5 Statement of Need

Please describe your current circumstances and why you are seeking financial assistance. Include any relevant financial, personal, or health-related factors. *

6 Impact Statement

How do you believe receiving this support will impact your life, health, education, or overall wellbeing? *

7 Additional Information (Optional)

Is there anything else you would like the review committee to know?

8 Certification & Signature

I certify that the information provided in this application is true and accurate to the best of my knowledge. I understand that funding decisions are made at the discretion of Be Well Circle and are based on available funds and demonstrated need.

Full Name (as signature) *

Date *

Your application is confidential and will only be reviewed by the Be Well Circle board.
Questions? team@remedycharleston.com

Application Received

Thank you for reaching out. The Be Well Circle board will review your application and be in touch. We're honored you trusted us with your story.