The Breakthrough Fund Application
ENROLLMENT IS OPEN ON A ROLLING BASIS
Applicant Name
*
First Name
Last Name
Male/ Female
*
Male
Female
Other
Address (must be NY resident)
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Applicant Date of Birth (Must be at least 6 years old)
*
-
Month
-
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
How did you hear about The Breakthrough Fund?
*
Which Providers Are You Interested In?
*
Able Athletics
Breakthrough Fit Co.
Swim Angel Fish
Chew On That
Jennifer Hill Yoga
Shames Swim - JCC
In one paragraph, please state why you believe health and wellness is important.
*
Please make a brief statement describing why the applicant is in need of financial assistance.
*
What is your occupation/ job title?
*
What is your spouse's occupation?
If applicable.
Is the applicant currently enrolled in any programs through the Office for Persons with Developmental Disabilities (OPWDD)? Learn more about OPWDD at https://opwdd.ny.gov/.
*
Yes
No
If yes, please list the OPWDD program(s)
2025 Adjusted Gross Income (Maximum income threshold of $120,000/year)
*
Number of Dependents under 18
*
Please list any applicable medical diagnosis
*
By signing this document, I agree that the information presented therein is accurate.
Applicant or Legal Guardian Name
*
First Name
Last Name
Applicant or Legal Guardian Signature
*
2025 Tax Return:
*
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Physician note detailing medical diagnosis:
*
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Please Note: Financial assistance is not guaranteed. It will be determined based on the viability of your application. Assistance will be given based in the availability of funds and level of need. This application is confidential. The information on the form will not be disseminated. We will notify applicants of the award amount within 2-4 weeks. Need is the most important priority for the Financial Assistance Program.
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