Walking with Cora Foundation
GRANT APPLICATION
Walking with Cora Foundation is dedicated to helping those families dealing with the unique challenges of a child with Cerebral Palsy, Genetic Disorders, or other neurological disorders. Thank you for taking the time to refer a child for a grant opportunity to receive pediatric therapy or equipment . The first step to determine eligibility for a grant is to complete this application in its entirety.
Please be advised a completed application does not guarantee a grant will be provided.To determine eligibility, the child must meet the following requirements at the time the grant application is received.
Please check all that apply:
The child must be under 18 years of age and a U.S. resident.
The child must be diagnosed by a licensed medical professional and under the care of a pediatrician.
The request must be clinically relevant to the health of the child with a specific health care need and not be covered byany other funding source.
One request per year, per child for a maximum of three times in a child’s lifetime or Funding Request is for one time orshort term assistance.
What is your relationship to the child?
Parent/Legal Guardian
Relative/Family Member
Other
How did you hear about The Walking with Cora Foundation?
Website
Intensive Therapy for Kids Blog
Friend
Instagram
Facebook
Other
Your Contact Information
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
E-mail
example@example.com
Phone
Child's Information
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Gender
Male
Female
Has this child ever received funding from The Walking with Cora Foundation or any other nonprofit organization?(Yes or no. If yes, please explain. Provide the organization name and year funding was received.)
Child's Family Information
Parent/Guardian First Name
Last Name
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.
Relationship to Child
Language
Current yearly household income
Child's Medical Information
Primary Diagnosis
ICD Code (International Classification of Disease code):
Diagnosis Date
-
Month
-
Day
Year
Date
Child's Pediatrician Information
Name of Pediatrician
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com
Child's other healthcare providers, if applicable
Therapists, Special Needs Clinics, Other Specialists, etc.
Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com
Type of Treatment Received
Does the child have health insurance coverage?
Yes
No
If no, please explain why the child does not have health insurance coverage.
Your grant request (please pick one): Again, please be advised a completed application does not guarantee a grant will be provided.
Attend LEAP Pediatric Intensive Therapy Grant
Other Pediatric Therapies or Equipment
If you chose 'Other Pediatric Therapies or Equipment' (please be as specific as possible)
Please provide the tentative date(s) of when and where you are attending treatment/therapy:
-
Month
-
Day
Year
Date
Where
Please provide an invoice and/or statement indicating the total cost of the above checked item. Please explain or attach anyother information you feel would be helpful to the Grant Request Application.
Your Story - Please tell us in more detail about your and your child's situation, story etc.
Submit
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