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Needs Request Application

FUND IT FORWARD operates on a pay it forward model: Families who receive help from FUND IT FORWARD agree to volunteer and fundraise for another family's need.
If you are not able to agree with this model, we are unfortunately not able to support your request.

Families are strongly encouraged to fundraise before requesting a gift of medical or adaptive equipment for their child. Each applicant is reviewed based on a number of criteria which includes fundraising efforts. Successful volunteer fundraising events determine how many families - like yours - FUND IT FORWARD can assist.

* = required fields

 

   

Patient (Child) Information

Name of child *:


Date of birth (MM/DD/YYYY)*:


Diagnosis *:


Parent / Guardian Information

Name of parent / legal guardian *:


Address *:


City *:


State *:


ZIP code *:


Phone number *:


E-Mail address *:


Please tell us about your needs:

For what type of equipment are you requesting funding?
Currently, we are not able to offer funding for any other equipment. Thank you for understanding.

 Seizure monitor
 Enclosed bed
 Adaptive bike
 Communication device
 Adaptive equipment

Equipment detail *:

Please enter specifics such as brand, approx. cost etc.:

Provide your child's story and explain how the equipment would help your family.
Click here for examples.


Please tell us how you plan to fundraise:

If you apply for financial help from FUND IT FORWARD, you are agreeing to volunteer / fundraise for another family's need. If you are not able to agree with this model, we are unfortunately not able to support your request.

I agree to organize a fundraiser.

Describe your fundraising idea.
Click here for examples.


 

How did you find us?

 Google, searching for:
 Personal recommendation from:
 Link from other Website:
 Facebook
 Article/Ad in (magazine):
 Special event (place/date):
 Other:

Enter verification code *:





 

 

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