Moving Mountains Foundation helps ensure that individuals with disabilities are afforded the opportunity to live a life where daily living tasks are possible. Oftentimes, increased levels of independence for individuals with disabilities can be achieved with improved access to needed medical equipment, supplies, or disability aid support that they need. Moving Mountains Foundation helps fund medical equipment and supplies while also financing aids and assistants that help persons with disabilities travel, communicate with others, learn, work, and participate in social and recreational activities.
Applicants must have an immediate need for treatment or documented medical support and if treatment is not found, the applicant’s physical safety is in jeopardy
The income level of the applicant’s family must be below $45,000/year
The case must involve an individual with a specific and documented health care need
The request must be clinically relevant to the health of the child or adult with a documented health care need
There must be no existing insurance coverage for the requested expenses
Fill out the application completely and legibly. Incomplete or illegible applications cannot be processed.
Email your completed application to: firstname.lastname@example.org
Moving Mountains Foundation will respond to your email within four weeks of it being sent either requesting more information or stating whether or not your request will move to the formal decision stage.
As soon as Moving Mountains Foundation has all of the needed information from you, the case will be decided at Moving Mountains Foundation monthly board meeting.
If approved, Moving Mountains Foundation will send funding to the provider or organization (not the family) within three weeks of approval. Rx: If approved, Moving Mountains Foundation will pay the vendor (not the organization or individual) directly on behalf of the recipient.
Funds must be used within twelve months of the date granted. All unused funds will be returned to Moving Mountains Foundation.
Moving Mountains Foundation
Application for Assistance
***If applying as an organization only fill out responsible party and organizations name***
Applicant’s or organizations name: __________________________________ Date of Birth: __________
Age: _________ Gender: □ Male □ Female Diagnosis: __________________________________
Responsible Party (If applicable): ___________________________________
Address: ______________________________ City:__________________ State: ______ Zip: ____________
Telephone: (Home): __________________ (Email): _______________
Child lives with___________________________ Number of dependents in household: _____________________
Household annual income: _____________
Emergency Contact Name:______________________________________Telephone:____________________
Funding Information Does the individual have health insurance? Yes____No____
Has funding been requested from additional sources? Yes____No____
If yes, please list why funding was not provided: _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Amount requested from Moving Mountains Foundation $ ___________________
Medical Information (Health care professional associated with funding request)
Healthcare professional’s name: _________________________________ Clinic Name: _____________________
Address: ______________________________ City:__________________ State: ______ Zip: _____________
Telephone: ____________________________ Fax: ______________________________________________