Grant Request Form

The WillPower Foundation provides grants to families and individuals with different abilities when insurance or other institutions do not. Grants can be made for up to $500 per family/individual per year, and cover a range of needs including mobility or sensory equipment, direct therapy, clinical evaluations, or special programming (such as summer camp).

Eligibility for WillPower Grants will be determined by availability of funds as well as the following criteria:

• The person receiving the grant must live within our service area – Hampshire, Hampden, Franklin or Berkshire Counties.
• Priority will be given to requests for products/services/programs which are not easily accessed through insurance or other resources. Examples include therapeutic riding lessons, sensory equipment, summer camp programs, etc.
• Priority will be given to requests that clearly explain how the service/equipment will benefit the individual with different abilities (including diagnosis and a description of the person’s needs).
• Priority will be given to requests which include letters of support from a therapist, teacher, or someone who knows the applicant well and can testify to the validity of the request.
• Priority will be given to requests which include specific dollar amounts and a breakdown of expenses. Whenever possible, vendor information must be supplied so payment can be made directly to the therapist, service provider, vendor, etc. Only one item or service may be requested at a time.
• At the present time no requests for computer hardware (i.e. iPads, laptops, etc.) will be considered. Funding requests for specialized software (i.e. the Proloquo2go app for iPad, iTouch or iPhone) will be considered on a case-by-case basis.

The Board of Directors meets regularly to review applications.  We will contact you about the status of your application following these meetings. In the meantime, please address any questions you have to info@willpowerfoundation.org.

To submit an online application for funding assistance, please complete the form below and provide as much detail as possible regarding how the money will be used to assist your family member/yourself. If you would rather download a PDF version of the Grant Request Form and mail it in, please click here. 

Date of Application:

Amount Requested (maximum $500):

Name of Person requesting funds:

Address:

City:

State:

ZIP:

Home Phone:

Cell Phone:

Email:

Name and Social Security Number of person for whom you are requesting funds:

if different from above.

Address:

City:

State:

ZIP:

Home Phone:

Cell Phone:

Email:

For what purpose are you requesting funds? (Only one product or service per request, please):

Itemized expenses for requested product/service (please be as specific as possible):

Describe the individual’s disability or area of need, and explain how the service or product you are requesting will benefit him or her:

Name and contact information of person or company from whom you will purchase this product or service:

Please describe any time considerations (i.e. do you need the money by a certain date for a scheduled program like camp? Are there any deadlines we should be aware of for a requested service?):

Is this product or service covered by insurance, or has it ever been covered by insurance?

Yes No

If yes, have you applied for insurance coverage for this product/service?

Yes No

Please explain:

Have you explored other options for funding?

Yes No

Please explain:

Due to the large number of requests we receive, some applications are only partially funded. If you are approved for an amount which is less than what you requested, will you be able to provide or secure additional funds in order to purchase the requested service or product?

Yes No

Please explain:

How did you hear about the WillPower Foundation?

Web search and/or WillPower Foundation website

School

Friend or family member: Name:

Therapist, doctor, or other service provider: Name:

Other:

Please enter security code (case sensitive)