Clone of Q2 2025 Northwest PANDAS/PANS Network Cedar Grant Application (Q2)

2025 NWPPN Cedar Grant Application (Q4)

The information provided on this form will be used by the NWPPN Board of Directors to determine eligibility and determine grant awards.
CONTACT INFORMATION
Applicant's Name (Person with PANDAS/PANS for whom the funds will be used)*

First NameLast Name
Person completing the Application (Parent, Guardian, Caregiver, Self, Etc.)*

First NameLast Name
Phone Number*

Area CodePhone Number
Address (this is where the grant check will be mailed)*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
E-mail for NWPPN Correspondence (including notifications, awards, etc)*
Applicant's Date of Birth*

MonthDayYear
How old is your child currently?*

FINANCIAL INFORMATION
What grant amount are you applying for?*
Do you have medical insurance?*

Yes, through an employerYes, through the health exchange where we purchase health insurance privatelyYes, through the state Medicaid systemNoOther
Who is your medical insurance through? (BCBS, Pacificsource, Medicaid, Aetna, United Healthcare)*
Health Insurance Carrier
Please describe your current financial situation and how it is prohibiting the necessary treatment you are seeking.*
What is your family's combined annual income?*
What is your family's estimated debt obligation currently (including credit cards, lines of credit, unpaid medical bills, liens, etc. DO NOT INCLUDE HOME MORTGAGES). *
How many of the applicant's guardians receive paid employment that financially support the applicant?*
How many dependents are living in the household including the applicant?*
Dependents
Do you/your family have other sources of income (ex: government aid, fundraisers, crowdfunding, a grant from an alternative foundation other family members supporting you)?*
Prior tax year return (1st page only)*

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PROVIDER INFORMATION:
Provider first and last name*
Provider specialty*
Provider address*
Provider phone number*
List other members of your medical team*
Have any other family members been diagnosed with PANDAS/PANS/AE*

YESNON/A

MEDICAL ELIGIBILITY:

NWPPN will determine medical eligibility with the help of the applicant’s treating US medical provider. You only need to submit this IF this is your FIRST TIME APPLYING. If you have applied previously, please submit any type of documentation that verifies your continued treatment under your P/P provider (visit note, bill, etc). The medical provider's letter must meet the following requirements: 1) Addressed to NWPPN 2) Written on the provider's letterhead 3) Signed by the provider 4) Include a confirmed diagnosis of PANS/PANDAS/AE 5) Include the applicant’s name, date of birth and a brief case history. A positive lab test does not replace the need for a provider's letter. A treating provider is defined as a MD, ND, DO, PA-C or NP. NDs must have graduated from a CNME accredited institution. The grant application is not complete and eligible for consideration by the Board of Directors until NWPPN has received the provider's letter. The letter must be dated within the last two years of date of application.
Medical Provider's Letter of Eligibility or Documentation of recent visit for returning applicants (or have them email to nwestppn@gmail.com).

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Additional provider letters can be uploaded here:

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MISC:
How did you hear about Northwest PANDAS/PANS Network (NWPPN)?*
How would the Cedar Grant from NWPPN be beneficial to your healing path?*
Is there anything else you would like to tell us?*

APPLICATION SUBMISSION

Attestation
My signature below indicates my attestation that all application answers are truthful and that I understand and agree to the terms of the scholarship award which include:

o   A grant covers expenses relating to the treatment of PANS & PANDAS. This includes medication, supplements, doctor visits, lab testing, and/or alternative practitioners (acupuncture, myofascial release). Should other PANS/PANDAS expenses arise, NWPPN will review on a case-by-case basis.

o   Grants may not be used for anyone other than the grant recipient and their care related to PANDAS/PANS. Grants may not be used for food, rent or mortgage expenses.

o What treatments do scholarship funds not cover? Non evidence based treatments such as homeopathy, ozone therapy, muscle testing, energy work, etc

o What expenses do grants money cover? The purpose of scholarship funds is to allow for continued treatment with a look back period of 3 months from award date for UNPAID eligible expenses.

o   NWPPN will release all of the grant money upon application approval. In order to remain eligible for future awards, all receipts for grant money must be submitted to NWPPN for the amount allocated.

o   Grant recipients must agree to submit an impact statement following their scholarship award that can be shared with potential donors, the NWPPN BOD and anonymously on social media/website.

o   NWPPN Board of Directors will determine medical eligibility with the help of the applicant’s treating US medical provider. The medical provider’s letter must meet the following requirements:
o   Addressed to NWPPN BOD
o   Written on their letterhead
o   Signed by the medical provider
o   Confirm the diagnosis of PANS/PANDAS
o   State applicant’s name, date of birth and provide a brief case overview
o   A treating provider is defined as an MD, ND, DO, PA-C or NP. The grant application is not complete and eligible for consideration by the Board of Directors until we receive the provider’s letter.
Submission Time*

MonthDayYearHourMinutesAM/PM Option
Signature*

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