Fall 2026 Grant Application

Fall 2026 Grant Application
- Applicant's Full Name
  
  First NameLast Name
- Applicant's Email Address
  example@example.com
- Applicant's Phone Number
  Please enter a valid phone number.Format: (000) 000-0000.
- Applicant's Address
  
  Street Address
  
  Street Address Line 2
  CityState / ProvincePostal / Zip Code
- Child's Full Name
  
  First NameLast Name
- Child's Age:
- Child's Date of Birth
  
  MonthDayYear
  2 digit month, 2 digit day, 4 digit yearDate
- Child's Disability or Diagnosis:
- Type of Grant Requested
  
  Other
- Describe the Therapy or Equipment Requested and How it Will Benefit your Child:
- Name of Therapy Clinic or Equipment Vendor:
- Has insurance been asked to cover this request?
- Has this therapy, equipment, or service been recommended by a medical provider or therapist?
- If requesting funding for intensive therapy, are you already scheduled, if so, what is the start date?
  
  MonthDayYear
  2 digit month, 2 digit day, 4 digit yearDate
- If requesting funding for intensive therapy, is this your child's first intensive therapy?
- Total Cost (USD):
- Amount Requested from WolfPups (USD):
  $2,500 Maximum for Equipment, $1000 Maximum for Therapy
- Without financial assistance, how likely is it that your child will receive this therapy or equipment within the next 12 months?
- If this request cannot be funded, what is the most likely outcome?
- In the past 12 months, have you delayed, declined, or stopped a clinician recommended therapy or equipment because of cost?
- Which areas of your child’s life would improve if this request were funded? (Select all that apply.)
- Which ONE area would improve the most? (Select one.)
- Annual Household Income:
- Number of People Living in Home:
- Has your family’s income been impacted because of your child’s disability?
  
  Other
- Have your child’s disability-related expenses affected your family’s finances in any of the following ways? (Select all that apply.)
  
  Other
- In the past 12 months, have you pursued or paid out of pocket for any therapies, treatments, or programs not covered by insurance? Are you planning to pursue any additional out-of-pocket treatments or programs in the next 12 months? If yes, please briefly describe.
- Insurance Coverage (select all that apply)
- Does your child currently receive any of the following? (Select all that apply.)
- Have you applied for funding through another organization for this same request?
- Why is this request needed now? (Select all that apply.)
  
  Other
- In 200 words or less, tell us how receiving this grant would change your child’s daily life. Please focus on the impact this funding would have on your child’s opportunities, independence, participation, or quality of life.
  
  0/250
- Is there anything else you would like us know?
- If you would like to upload a short video/photo about your child/family, please feel free to do so!
  
  Cancelof
- You may upload supporting documents here (e.g. therapy referrals, quotes, insurance denials, etc. Please redact policy numbers, medical record numbers and any personal identification information except for name)
  
  Do not stress if you do not have all of these ready, if selected, we will ask for them during the finalization process.
  Cancelof
- WolfPups on Wheels loves to share the stories of the families we serve — on social media, our website, and in other communications. This helps us raise awareness, grow our community, and support more families like yours. However, sharing your story is completely optional and has no impact on your application or your ability to receive a grant. If selected for a grant, would you be willing to allow WolfPups on Wheels to share your child's story and/or photos on our social media, website, or other communications?
  If you consent, we will contact you before posting anything to confirm the specific details you are comfortable sharing. You may withdraw consent at any time.
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