Foundation Grant Application

There is no time limit to complete this application. But, if you close this page before it’s submitted, your changes won’t be saved and you’ll need to start over.

One of the charitable purposes of The Henrietta Lacks Foundation, Inc. (“Foundation”) is to provide financial support to individuals with financial need who have made significant contributions to scientific research without informed consent or without reciprocal benefit, including without limitation contributions of biological material made unwillingly or unknowingly, or a family member of such persons.

If you have any questions, please email grants@henriettalacksfoundation.org.

Instructions

In order to help the Foundation identify appropriate beneficiaries of the Foundation’s financial grants (“Foundation Grants”), please complete the application below and submit it, with appropriate attachments for the Board to review.

Grant Application

Step 1 of 5 - Part I

PART I
Name*
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Email*
Date of Birth*
Month
Day
Year

PART II
Please complete this section to help the Foundation understand how you plan on using the Foundation Grant, should you receive one.
How will this Foundation Grant be used? (College, tutoring service, social programs, medical aid, etc.)*
Contact Information
Please provide the name, address, website, and any other available contact information for the educational institution or comparable entity on which you are proposing to spend the Foundation Grant.
Name of the Institution or Comparable Entity*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Website
Phone (including area code)*
Other Information
Financial Support
How much financial support are you requesting from the Foundation? (Please provide an exact amount of financial assistance you are requesting and the duration of time for which it will be used - i.e. single class, one semester, one quarter, one year, etc.)
Dollar Amount*
Duration of Time*
If you receive a Foundation Grant, might you reapply in the future? If so, when?*
Please itemize how the Foundation Grant funds will be used (tuition, books, specific examples of living expenses, etc. and how much of the total grant will be applied toward each).*
Scores
If you are applying for a Foundation Grant for educational purposes, please provide scores for any SAT’s, ACT’s, GRE’s, or any other similar examination that you have taken. If you have not taken tests of this kind, you may skip this question.
SAT
ACT
GRE
Other
Additional Evidence - Government Grants
Please include either (a) or (b) in your application:
a) Written evidence that you have made good faith attempts to obtain government-sponsored financial aid for your anticipated costs/needs listed in the "Financial Support" section above, including, but not limited to: Medicare, Medicaid, the Federal Pell Grant, and the Federal Supplemental Education Opportunity Grant (collectively referred to as “Government Grants”)
Max. file size: 50 MB.
b) Written evidence that the Government Grants do not cover the anticipated costs/needs listed in Item 6 above.
Max. file size: 50 MB.
Additional Evidence - Medical Care
If you are applying for a Foundation Grant to cover expenses of medical care:
Please include in your application an estimate from your medical care provider indicating the anticipated cost of the medical care in question, and either a or b below:
a) Proof that your existing medical insurance does not cover the anticipated cost of the medical care in question, OR
Max. file size: 50 MB.
b) Letter from a medical provider indicating you do not have the necessary insurance coverage for the medical care in question
Max. file size: 50 MB.
Additional Evidence - Taxes
Please include in your application copies of Internal Revenue Service (IRS) federal tax returns for you and/or your immediate family for the last two (2) calendar years.
Max. file size: 50 MB.

PART IV
Please provide two personal references (who are not directly or indirectly related to you, and are not members of the Foundation’s Board of Directors).
Reference 1
Name
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Years Known
Relationship
Reference 2
Name
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Years Known
Relationship
Submit
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IMPORTANT INFORMATION
At its sole discretion, the Foundation may follow up with you for more information (including, without limitation, financial information) to help make its decision with regards to your Application. Please note your submission of this Application for a Foundation Grant does not guarantee you the Foundation’s financial support. The Foundation will consider an assortment of factors in identifying the appropriate beneficiaries of the Foundation Grants, including, without limitation: availability of funds, number of applicants, financial status, and individual need.

Grant Application

Step 1 of 5 - Part I

PART I

PART II

Contact Information

Financial Support

Scores

Additional Evidence - Government Grants

Additional Evidence - Medical Care

Additional Evidence - Taxes

Net Worth Statement Worksheet

Liabilities

Total

PART III

PART IV

Reference 1

Reference 2

Submit