Moving Mountains Foundation Application for Equipment

Moving Mountains Foundation Application for Assistance

*If applying as an organization only fill out the responsible party and organization's name *

Applicant's or organization's name

Date of Birth

Date

Item being requested with description and/or link:

Justification for why item is needed and its impact on individual’s needs:

Amount requested from Moving Mountains Foundation

in dollars

Responsible Party (If applicable)

Address

Street Address Line 2

CityState

Zip

Telephone: (Home)

Format: (000) 000-0000.

(Email)

example@example.com

Applicant lives with

Number of dependents in household

Household annual income (additional documentation may be requested as needed)

Emergency Contact Name

Telephone

Format: (000) 000-0000.

Funding Information: Does the individual have health insurance?

Has funding been requested from additional sources?

If yes, please describe why funding was not provided:

Health care professional associated with funding request

Healthcare professional's name

Clinic Name

Telephone

Format: (000) 000-0000.