1) Name of the person this grant will impact

2) Date of Birth

3) Disability (REQUIRED: Please attach a signed letter from MD or therapist verifying disability)

4) Name of person completing this application

5) Contact Phone Number and Mailing Address

6) Please tell us a little bit about the person this grant will impact (pictures are welcome but not required)

7) Please indicate specifically what you are seeking grant funding for (REQUIRED: please include quote for this service as we must pay vendors/programs directly)

8) Have you received any other grant funding this year?

9) We are growing our social media presence in order to help our foundation grow. If you are chosen can we share selected information? (Your answer does not impact your chance in winning a grant)