Grant Application

Call (313) 744-3488 for questions or help with this form.

Contact Information

First Name:
Last Name:
Address 1:
Address 2:
City:
State:
Zip Code

Contact Preferences

Phone Number

DaytimeEvening

E-Mail Address

Purpose of Item being requested

Health or Self-careCommunicationProductivityOther

Other Catagory

Item Description

Below, please provide a description of the item you will be purchasing. The reason for the item and how it will increase your independence. The cost, place of purchase, and include a link to the item if possible. Someone from the committee will contact you within 30 days. Thank you.

Item Description and other comments:

Payment Method:

Please select which method you would like to receive your payment.

By MailPayPal

If you chose PayPal above, please provide the email address you wish the payment to be sent to.