Acute Flaccid Myelitis Grant Application
Grants of up to $5000 will be awarded for qualifying applicants in need of assistance. The distribution of funds is based on necessity and urgency of need. Grants may be used for equipment, medical costs, respite care and other associated costs directly related to an Acute Flaccid Myelitis diagnosis. Please be specific in explaining the need for a grant. A written medical diagnosis, vendor bills and other documentation will be requested at the time of the award.
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Email *
Name of Person Living with AFM *
Current Age of Person with AFM *
Street Address *
City *
State *
Zip Code *
Phone Number *
Date of AFM Diagnosis *
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DD
/
YYYY
Annual Household Income (AFMA may request a recently filed tax return for verification) *
Grant Amount Requested (up to $1000) *
Please describe the degree of your disability and how it affects everyday life (100 words max): *
Please give a brief explanation of how the equipment or modification(s) for which you are applying would impact daily life (250 words max): *
Primary Caregiver *
Relationship to Person Living with AFM *
Primary Caregiver Address/City/State/Zip (if different)
Primary Caregiver Email (if different)
Primary Caregiver Phone Number (if different)
I acknowledge that I am aware that if I receive a Acute Flaccid Myelitis Association grant, my child's name/image may be used by the AFMA for media and/or promotional purposes. *
By signing this application you agree: To indemnify AFM Association for any injuries, accident or injuries that may occur through the use of the funds. AFM Association is not a party to the contract between the grantee and the contracted party for services. *
A copy of your responses will be emailed to the address you provided.
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