Equipment | Standard Application - Moving Mountains Foundation

Name *

First

Last

Phone Number

Email *

Address

City, State, ZIP

What is the equipment for which you are requesting funds? *

How will this equipment make your life better? *

List anything that will make you safer or more independent in travel, communicating, learning, work, or social and recreational activities.

Amount Requested *

If the amount requested is less than $200, don't use this form. Use the short form.

Household Income *

Medical Expenses

This does not include the expense for which you're requesting funding.

Number of People in Household *

Including you.

If you are not at or below the federal poverty level, we will require you to cover 25% of the cost of your equipment. Do you intend to contribute to the cost of your equipment? *

Yes
No

If you are contributing to the cost of your equipment, please state how.

Funds
In-Kind Donation
Community Service Hours

If you are using community service hours to contribute to the cost of your equipment, please reach out to us beforehand. You can email us at foundation@mmtherapycenter.com or call us at 406-396-4130.

Do you have health insurance? *

Yes
No

Has funding been denied by your health insurance? If funding was denied, please state why.

Check all that apply:

This question is for grant-reporting purposes. It will not be considered in deciding whether or not you receive funding.

Have we served you before? *

No
Yes, through funds or grants
Yes, in some other way

Preferred Contact Method

Phone
Email

What's the best way to get in touch with you?

Name of healthcare provider *

First

Last

We'll need a letter from your doctor or other healthcare provider with the relevant diagnosis, specific request for funding, and any other important information. This can be emailed to foundation@mmtherapycenter.com or faxed to 406-797-5008.

Name of Clinic

Provider's phone number *

Anything else we should know?

I certify that the information above is true and give Moving Mountains Foundation permission to contact my healthcare provider as necessary. *

Yes
No