Individual Grant Application

Thank you for your interest in an ATI Foundation individual grant. Grant applications are accepted on a rolling basis. Prior to completing your application, please review our Grant Application Guidelines and FAQs, attached at the bottom of this application.

Your Contact Information

First Name *

Last Name *

Email *

Applicant Information

If you are applying for assistance, please fill out the fields below with your information. If you are applying on behalf of someone else, please list the applicant's information.

Are you applying on behalf of someone else? * The field Are you applying on behalf of someone else? is required.

Applicant Name The maximum length for the field Applicant Name is 500 characters.

Relationship to Applicant The maximum length for the field Relationship to Applicant is 500 characters.

Applicant Date of Birth * The date field Applicant Date of Birth is required.

Applicant Gender * The field Applicant Gender is required.

Phone * The phone field Phone is required.

Address * The field Address is required.

Address Line 2 The maximum length for the field Address Line 2 is 500 characters.

City * The field City is required.

State * The field State is required.

Zip Code * The numeric field Zip Code is required.

Referral Information

The ATI Foundation accepts individual beneficiary applications on a referral basis. Please provide the information of the person who referred you below.

Referral Contact Name * The field Referral Contact Name is required.

Clinic / Office Location * The field Clinic / Office Location is required.

Background Information

Tell us about why you are seeking assistance from the ATI Foundation.

Does the applicant have a physical impairment? * The field Does the applicant have a physical impairment? is required.

What is the applicant's physical impairment/diagnosis? Include all relevant diagnoses, if multiple. * The field What is the applicant's physical impairment/diagnosis? Include all relevant diagnoses, if multiple. is required.

Has the applicant ever received a grant from the ATI Foundation? * The field Has the applicant ever received a grant from the ATI Foundation? is required.

Has the applicant been denied a grant request in the past by the ATI Foundation? * The field Has the applicant been denied a grant request in the past by the ATI Foundation? is required.

If you answered "Yes" to either of the previous questions, please provide additional detail, including the year you applied. The maximum length for the field If you answered "Yes" to either of the previous questions, please provide additional detail, including the year you applied. is 500 characters.

What is your need? * The field What is your need? is required.

If you selected "Other", please describe. The maximum length for the field If you selected "Other", please describe. is 500 characters.

Amount Requested (typical grant range is between $2,500 and $7,500): * The numeric field Amount Requested (typical grant range is between $2,500 and $7,500): is required.

Is there a specific date the applicant needs to secure funds for this need by? (Application process takes a minimum of six weeks) * The field Is there a specific date the applicant needs to secure funds for this need by? (Application process takes a minimum of six weeks) is required.

If you selected "yes", what date are you hoping to secure funds for this need by? The field If you selected "yes", what date are you hoping to secure funds for this need by? must be a date.

Tell Us Your Story

Please utilize the fields below to describe your need for assistance in further detail.

Why are you seeking an ATI Foundation grant? * The field Why are you seeking an ATI Foundation grant? is required.

How will a grant from the ATI Foundation help the applicant lead a more fulfilling life? * The field How will a grant from the ATI Foundation help the applicant lead a more fulfilling life? is required.

What is your annual household income? * The field What is your annual household income? is required.

Please describe your need for financial assistance in detail: * The field Please describe your need for financial assistance in detail: is required.

Additional Funding Source Information

Please utilize the fields below to describe additional funding sources, if applicable.

Does the applicant have primary insurance? * The field Does the applicant have primary insurance? is required.

Does the applicant have secondary insurance? * The field Does the applicant have secondary insurance? is required.

What efforts have been made to submit a claim through applicant's insurance for these needs? * The field What efforts have been made to submit a claim through applicant's insurance for these needs? is required.

Has the applicant contacted any other organizations for financial assistance regarding this need? * The field Has the applicant contacted any other organizations for financial assistance regarding this need? is required.

If you answered "yes" to the previous question, please list the organizations applied to, amounts, and status of that application: The maximum length for the field If you answered "yes" to the previous question, please list the organizations applied to, amounts, and status of that application: is 5000 characters.

Document

For more information on our application process and eligibility requirements, please review our Grant Application Guidelines and FAQs below:

Grant Application Guidelines and FAQs.pdf