Walking with Cora Foundation
EQUIPMENT 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 Equipment . The first step to determine eligibility for a grant, is to complete this application in its entirety.
Please select YES below. By selecting YES, you understand that this an application for Equipment ONLY and not for Therapy. By filling out this application it DOES NOT automatically put you in the running for a Therapy Grant. You MUST fill out a SEPERATE application to be eligible for a Therapy Grant.
YES, I understand that this is an application for Equipment ONLY!
Disclosure
***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 by any 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
Does the child have health insurance coverage?
Yes
No
If no, please explain why the child does not have health insurance coverage.
Please provide a detailed description as well as a link or an invoice/statement indicating the total cost of the piece of Equipment that is being requested, be as detailed as possible. Please explain or attach any other information you feel would be helpful to the Grant Request Application.
Please select the word YES below. By selecting YES, you understand that this application is for Equipment and NOT for Therapy. . . There is another application for Therapy and by filling out this application for an Equipment Grant DOES NOT automatically put you in the running for a Therapy Grant. You MUST fill out a SEPERATE application to be considered for a Therapy Grant ***Please be advised a completed Equipment Grant application DOES NOT guarantee a grant will be provided.
YES, I understand that this an application for an Equipment Grant ONLY
Your Story - Please tell us in more detail about you and your child's situation, and how this piece of equipment could be beneficial.
Submit
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