Grant Application Form
The goal of our Family Empowerment Grant is to support families with expenses related to their child with unique abilities. Examples may include co-pays or deductibles for therapies, fees not covered by insurance or other funding sources, etc.
Learner Name
*
First Name
Middle Name
Last Name
Learner Date of Birth
*
-
Month
-
Day
Year
Date
Home Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
E-mail
*
example@example.com
Father's Name
*
First Name
Last Name
Mother's Name
*
First Name
Last Name
Please describe how you will use any funds awarded to your learner. Example: describe therapies or educational programs where these funds will be applied.
*
Name of Program
Cost of Program
Is your learner currently enrolled in this program?
*
yes
no, we are on waitlist
Amount of financial assistance needed in order to enroll your learner/keep learner enrolled:
*
Please upload a letter explaining why you believe your learner should be chosen to receive funds for program(s).
*
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