Specialty Mobility Equipment RequestNatasha2020-01-03T11:56:40+00:00 [[[["field11","equal_to","YES"]],[["show_fields","field4"]],"and"]] 1 Step 1 Disabled Child’s Name: Age Weight Name of Parent, Guardian, or Caregiver applying for award Relation to Child Street Address Apt/Unit/Floor City State Zip Code Phone Number Email Address Child’s Disability Information0 / What type of specialty mobility assistance equipment are you applying for?0 / Primary reason for applying for specialty mobility assistance equipment?0 / How does child get to school, doctor/therapy appointments, store, etc. today?0 / Have you applied to any other programs (state/federal/charitable organizations) for financial assistance in purchasing mobility assistance equipment?YESNO If so, please provide the name, date and outcome from each:0 / Have you previously received any grant or financial award that ended in receiving or purchasing mobility assistance equipment items?YESNO If so, please provide the name, date contact number of each0 / Please list any current or past fundraising efforts in regards to purchasing or procuring mobility assistance equipment.0 / Provide a statement on why you should be considered to receive an award from Mobility Vans for Kids0 / If you desire, upload a video submission to support your application and provide a YouTube link Please provide the URL's or Links to any social media accounts of yourself, family, child, or organizations you are associated with.0 / Additional supporting information or comments0 / How did you find out about Mobility Vans for Kids? Submit Form keyboard_arrow_leftPrevious Nextkeyboard_arrow_right FormCraft - WordPress form builder By submitting this preliminary application, you certify that all statements and information above are true and correct and that you have read and understand the application guidelines.
