B & G Hope Grant Application Form
We are excited to share that the B&G Hope Grant is now proudly sponsored by the William Finn Walsh Fund.
The grant is open to physical therapists, occupational therapists, speech-language pathologists, ABA professionals, and other therapy providers who work with individuals with special needs. Rather than selecting one area of focus, we are asking the professionals who serve our community every day to tell us what they believe Southwest Louisiana needs.Applicants may propose a training, certification, therapy technique, resource, program, or other opportunity they believe could improve services and expand options for individuals with special needs in our region. All applications are due by October 20, 2026. **All training must be completed within 12 months of funds granted**
PERSONAL INFORMATION
All information is required*
Full Name
First Name
Middle Name
Last Name
E-mail
example@example.com
Phone Number
Format: (000) 000-0000.
Primary Place of Employment
Primary Employer's Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Do you provide therapy services at a location or facility outside your primary place of employment?
If yes, please provide the location name, address, phone number, and employer's email address.
Proof of License
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REFERENCES
Please provide two client references.
Reference Name
First Name
Last Name
Reference Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Reference Email
example@example.com
Reference Name
First Name
Last Name
Reference Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Reference Email
example@example.com
Application
Please describe the area of training, continuing education, or professional development you would like the B&G Hope Grant to fund.
Amount requesting.
If FFI is unable to cover the full cost, would you be willing to accept partial funding and still pursue the training?
Please Select
Yes
No
PROFESSIONAL BACKGROUND
What is your medical specialty or area of expertise?
Please provide a brief overview of your educational background and credentials.
How long have you been practicing in Southwest Louisiana?
How do you currently assess and treat children with motor delays or developmental challenges in your practice?
Have you received specialized training in pediatric therapy or developmental interventions? If yes, list them.
ADDITIONAL INFORMATION
As a provider, do you accept clients on Medicaid?
Please provide any additional information or insights that you believe are relevant to support your application for this grant.
Do you understand that all training must be completed within 12 months of receiving grant funds, unless an extension is discussed and approved by FFI in advance?
Please Select
Yes
No
Do you anticipate moving outside of the Southwest Louisiana region within the next five years?
Please Select
Yes
No
Do you understand that if you move outside of the Southwest Louisiana region within five years of receiving the grant, you may be required to repay Families for Inclusion the full or a prorated portion of the grant funds awarded?
Please Select
Yes
No
Signature
By signing this form, you are agreeing to allow Families for Inclusion to use your story, journey, and experience for our social media, website, and press releases.
Date
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Month
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Day
Year
2 digit month, 2 digit day, 4 digit year
Date
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