Direct Aid Reimbursement Application

Name of Applicant with Spina Bifida *

First

Last

Input the name of the individual with Spina Bifida.

Name of Parent or Guardian (if applicable)

First

Last

Input the name of the Parent or Guardian of the individual with Spina Bifida.

Address, Including City, State and Zip Code *

Input the Address, City, State and Zip Code of the individual with Spina Bifida.

Phone Number *

Input the Phone Number of the individual with Spina Bifida.

Email *

Input the Email Address of the individual with Spina Bifida.

Intended Purpose of the Request *

Input the Intended Purpose of the Request for Direct Aid.

Total Amount of Services or Goods per Invoices *

Send original invoices to info@sbaws.org

Your Participation with SBAWS *

Include your past or current participation with SBAWS, as well as what would interest you for future participation.

By checking these boxes and submitting this application, you agree to the following statements: *

This request is due to financial need and the funds will be used for the intended purposes. You recognize that checks will be made out to the supplier unless paid receipts are included with this application. You understand that SBAWS has limited funds and is normally only able to assist up to an annual maximum of $500 and will be awarded at the discretion of the SBAWS Board of Directors. You will be contacted about your request from SBAWS to confirm receipt and to assess situation. A final determination will be made at the next scheduled Board meeting (held every month), and you will be notified of the Board’s decision for awarding funding within seven (7) days following that meeting.
The applicant is a person with Spina Bifida (or that person’s parent/guardian) who resides within the SBAWS service area.
You will send your documentation to info@sbaws.org
All information provided is true and accurate.

Checkboxes