CEREBRAL PALSY ASSOCIATION OF MANITOBA
105-500 Portage Ave., Wpg. MB. R3C 3X1 - 982-4842 or 1-800-416-6166
GRANT APPLICATION FORM
These questions can be answered in a cover letter or on the back of the form.
2. DATE OF BIRTH OF INDIVIDUAL WITH CEREBRAL PALSY?
3. HAS THE APPLICANT/FAMILY BEEN A GRANT RECIPIENT IN THE PAST?
4. IS THE APPLICANT/FAMILY A CURRENT MEMBER OF THE CEREBRAL PALSY
ASSOCIATION? HOW MANY YEARS?
5. IS THE APPLICANT/FAMILY APPLYING ON HIS/HER/THEIR OWN BEHALF?
IF NOT PLEASE STATE WHO IS?
6. WHAT IS THE REQUEST? ATTACH DETAILS OF THE EQUIPMENT/ITEM(S) WITH
SPECIFIC COST(S) INCLUDING GST & PST IF APPLICABLE.
7. HOW WILL THIS REQUEST ASSIST THE INDIVIDUAL/FAMILY IN AREAS OF
PERSONAL, EDUCATIONAL AND/OR SOCIAL DEVELOPMENT LEADING TO A MORE
INDEPENDENT AND QUALITY LIFESTYLE? THIS CAN BE ADDRESSED IN YOUR
COVER LETTER.
8. PLEASE NAME ALL OTHER FUNDING SOURCES THAT YOU HAVE CONTACTED.
WHAT IS THE RESPONSE FROM THESE FUNDING SOURCES REGARDING YOUR REQUEST(S)? PLEASE BE SPECIFIC.
HOW WILL YOU OBTAIN THE ADDITIONAL COSTS NOT COVERED BY CPAM OR OTHER FUNDERS?
OFFICE USE ONLY - DATE APPROVED BY BOARD OF DIRECTORS BY A MOTION: __________________________________
DATE OF FOLLOW UP: ___________________________________________
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