Project Open House Application (MUST be accompanied by Participant Form)
Date:________________
Name of Applicant:________________________________________________________
Address:_____________________ Town: ____________________ Zip: _____________
Phone (Home): ____________ Phone (Work): ________
Date of Birth: ________________
Name of Disabled Person: ______________________________
Disability: _________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
Date of Onset of Disability: _______________________
Currently Using:
____ Walker
____
Wheelchair____
Crutches
____ Cane ____
Wheelchair with Motor
_____ Other
Yearly medical
expenses not covered by any aid: ________________________________
Why do you need this? _______________________________________________________
_________________________________________________________________________
_________________________________________________________________________
Do you: ______
Own Home ______ Rent Home ______ Rent Appt.
______ Other ______________________
- We request a $200 donation from each family as a match for our grant.
- Please
let us know if this $200 is a handicap, and we will try to work something
out.
- Currently our waiting period is 4-6 months