Apply for a Grant

The information in this application is confidential and protected under the Privacy Act. The information is to be used solely by the staff of Walking With Anthony in determining grant eligibility. If you have received this information in error, please destroy the documents or mail the originals to: Walking With Anthony 9903 Santa Monica Blvd. Suite 1024 Beverly Hills, CA 90212.

Grant Application

In an effort to provide the most safe and effective sponsor programs, we require all applicants to complete this application. Information contained on this application will remain confidential. After your application is reviewed, our office will contact you by e-mail or phone. The completion of this application does not guarantee your participation in our grant program.

Client Information

Client First Name

Client Last Name

Date

Address

City

State

Postal Code

Country/Region

Home Phone

Cell Phone

Email (Required)

Contact Information (if different than above)

Contact First Name

Contact Last Name

Date

Address

City

State

Postal Code

Country/Region

Home Phone

Cell Phone

Email (Required)

Date of Birth

Age

Height

Weight

Sex

Level of Spinal Cord Injury

Complete or Incomplete Diagnosis

Date of injury

Asia Level/Score

How were you injured?

At what hospital were you treated?

City

State

Treating physician

Date of last medical examination

Employment History

Present Employer

From

Job Title

City

State

Hours per week

Previous Employer

From

Job Title

City

State

Hours per week

Monthly Income

Average Monthly Income

Average Monthly Expenses

In case of emergency, please notify

First Name

Last Name

Relationship

Phone (home)

Phone (work)

Please provide a copy of your most recent income tax return

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APPLY FOR A GRANT

Grant Application