Acute Flaccid Myelitis Grant Application
Grants of up to $1000 are awarded on a monthly basis. They will be evaluated based on necessity and urgency of need. Grants can be used for equipment, medical costs, respite care and any other associated costs with an Acute Flaccid Myelitis diagnosis. Please be specific in explaining the need for grant. Receipts, bills or other documentation will be requested for further evaluation.
Email address *
Name of Person Living with AFM *
Your answer
Current Age *
Your answer
Street Address *
Your answer
City *
Your answer
State *
Your answer
Zip Code *
Your answer
Phone Number *
Your answer
Date of AFM Diagnosis *
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DD
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YYYY
Annual Household Income (AFMA may request a recently filed tax return for verification) *
Your answer
Grant Amount Requested (up to $1000) *
Your answer
Please describe the degree of your disability and how it affects everyday life (100 words max): *
Your answer
Please give a brief explanation of how the equipment or modification(s) for which you are applying would impact daily life (250 words max): *
Your answer
Primary Caregiver *
Your answer
Relationship to Person Living with AFM *
Your answer
Primary Caregiver Address/City/State/Zip (if different)
Your answer
Primary Caregiver Email (if different)
Your answer
Primary Caregiver Phone Number (if different)
Your answer
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. *
Your answer
A copy of your responses will be emailed to the address you provided.
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