Moving Mountains Foundation application for equipment

Moving Mountains Foundation Application for Assistance

***If applying as an organization only fill out the responsible party and organizations name *
Applicant's or organizations name
Date of Birth

Month Day Year
Date
Age
Gender

Male Female
Diagnosis
Responsible Party (If applicable)
Address

Address

Street Address Line 2

City State

Zip
Telephone: (Home)
(Email)
example@example.com
Child lives with
Number of dependents in household
Household annual income
Emergency Contact Name
Telephone
Funding Information: Does the individual have health insurance?

Yes No
Has funding been requested from additional sources?

Yes No
If yes, please describe why funding was not provided:
Amount requested from Moving Mountains Foundation
in dollars
Medical Information (Health care professional associated with funding request)
Healthcare professional's name
Clinic Name
Address

Address

Street Address Line 2

City State

Zip
Telephone
Fax Number
Please enter a valid phone number.
Should be Empty: