Scholarships - Moving Mountains Foundation

Name *

First

Last

Phone Number

Email *

Address

City, State, ZIP

What program are you applying for? *

How will this program benefit you? *

Amount Requested *

Household Income *

Medical Expenses

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

Number of People in Household *

Including you.

We will cover up to 100% of the cost of successful applicants at or below the federal poverty level. If you are not at or below the federal poverty level, we will fund up to 75% of your costs. Do you intend to contribute to the cost of your program? *

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?

Anything else we should know?

I certify that the information I have provided is true. *

Yes
No