Grant Application
Person completing this form:
First Name
Last Name
Name of child or person on whose behalf assistance is being requested:
First Name
Last Name
Your relationship to the child or person:
How did you hear about The Mitchell and Friends Foundation?
Another parent
A health care worker
An internet search
Other
If you are comfortable giving us the name and contact information of the person who referred you to The Mitchell and Friends Foundation, please enter that information below.
Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email:
example@example.com
Phone Number:
Please enter a valid phone number.
Format: (000) 000-0000.
Child or person's birthdate:
-
Month
-
Day
Year
Date
Year in school:
Current medical diagnosis of child or person:
Briefly describe the child or person's medical journey.
Grants from The Mitchell and Friends Foundation currently range between $0 and $2000. What size grant are you requesting?
What type of financial assistance are you requesting?
Help paying past medical bills
Help paying current or upcoming medical bills
Cost of living needs (utilities, groceries, housing, etc.)
Transportation needs (assistance to/from appointments, vehicle modifications)
Communication devices and assistive technologies (hearing aids, FM systems)
Medical equipment (wheelchair, orthopedics, hospital bed)
Home modifications (ramp installation, etc.)
Personal care equipment (bath and shower chairs, etc.)
Funeral costs
Sibling support
Other
Tell us more about the sort of assistance you are requesting, including why a grant would be helpful.
What is your average annual household income?
Are you employed? What is your occupation?
How many members are there in your household?
Have you requested help from any family members, churches, or other organizations? Were they able to assist?
Please share any additional financial circumstances that you think may be helpful for us to know as we review your grant application.
By what date do you need financial assistance?
Insurance carrier name:
Insurance carrier address:
Insurance carrier phone number:
Policy holder's name:
The Mitchell and Friends Foundation prefers to meet needs denied by insurance carriers. Please upload a letter from your insurance company denying the service or equipment. (Or email info@mitchellandfriends.org.)
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The Mitchell and Friends Foundation exists to support people of any age diagnosed with Mitchell Syndrome, and children under 18yo with other undiagnosed neurological diseases. Please upload a letter from your doctor confirming either. (Or email info@mitchellandfriends.org.)
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