CFMD Grant Application

The Colorado Fund for Muscular Dystrophy (CFMD) was established in 2012 by friends and family of Aileen Colorado, who passed away from complications from pneumonia in 2011. Born with congenital muscular dystrophy, Aileen never let her disability stop her from living a fulfilling life and a career helping people with disabilities. In memory of Aileen, CFMD made it their mission to increase the quality of life of individuals living with muscular dystrophy or a neuromuscular disorder. CFMD offers grants to individuals who are in need of financial assistance. Grants may be awarded for, but not limited to, equipment, therapies, medical supplies, home modifications, or recreation center membership, not fully covered by insurance. Grant applicants must be a United States resident with a diagnosis of any form of muscular dystrophy or neuromuscular disorders, including but not limited to:
- Amyotrophic lateral sclerosis (ALS)
- Charcot-Marie-Tooth disease
- Congenital Muscular Dystrophy
- Multiple sclerosis
- Myasthenia gravis
- Myopathy Myositis, including polymyositis and dermatomyositis
- Peripheral neuropathy
- Spinal muscular atrophy
The maximum request amount per application is $1,000, payable to a business. Grants will not be awarded to pay off loans or as reimbursement of items/services already purchased.

If we cannot grant your request for assistance, we will make an effort to suggest other possible resources that may meet your needs.

Please complete the application with the required additional documentation below. Incomplete applications missing the required documents will not be considered for the grant. Grants are awarded based on the availability of funds. Completed applications will be reviewed when received. Only applicants chosen to receive the grant will be notified by email or by phone.
Name of person submitting application:*
Relation to applicant:*
Email address:*
example@example.com
Phone number:*
How did you find out about the grant?*
Name of applicant:*
Date of Birth*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Type of Muscular Dystrophy or Neuromuscular disorder:*
Please upload a letter from the applicant's doctor verifying the medical condition and why applicant would benefit from item/services. *

Cancelof
Describe how the medical condition affects activities of daily living:*
Requested item/service:*
Total cost of the item/service: *
Please upload proof of cost (web link, invoice, etc.)*

Cancelof
Grant amount requested (max $1000):*
If the price of the item/service is over $1,000, do you have funds to pay the remaining balance?*

YesNo
Money will not be given directly to individuals. Money will be paid directly to the business providing the item or service.
Name of business contact providing item/service:*
Phone number of business contact:*
Do you currently receive any of the following resources (Check all boxes that apply)*

I do not currently receive any other financial resourcesPrivate InsuranceMedicaidMedicareSocial SecurityOther financial resources
Have you received assistance from the following:*

I have not received any other assistance.Department of social servicesDepartment of Aging and Rehabilitative ServicesGrants from other organizations within the current year (Amount/Organization)
- Financial assistance will not be awarded to pay off loans or as reimbursement of items/services already purchased,
- If we cannot grant your request for assistance, we will make an effort to suggest other possible resources that may meet your needs.
- All sensitive information provided on this application will be kept confidential and will not be sold or given to any third party for solicitation.
DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.
Applicant Signature:
Signature of parent/legal guardian if applicant is under the age of 18
Date

MonthDayYear
Date
Release Form:
I hereby give my consent to the Colorado Fund for Muscular Dystrophy to use the following in press releases to the media, publications, or advertising activities if I am chosen as a recipient of the grant: (Check the ones that you would allow)

My nameDiagnosed form of Muscular Dystrophy or Neuromuscular disorderName of the state where I resideName and description of the service or item that was purchased with the grantDescription of how the service/item has improved my quality of lifePictures I submit to CFMD
Applicant's Name:
DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.
Applicant Signature:
Signature of parent/legal guardian if applicant is under the age of 18
Date

MonthDayYear
Date
Should be Empty:

Release Form: