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First Name
Last Name
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Address Line 1
Address Line 2
City
State/Province
ZIP/Postal Code
Country
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(mm/dd/yyyy)
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Please indicate which category(s) best describe your race/ethnicity:
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If your insurance company has denied your request for this product/service, please upload the official denial letter.
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(mm/dd/yyyy)
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Please note: the maximum scholarship awarded is $5,000. Please input the amount you are requesting rounded to the nearest dollar and without a comma. The amount should match the estimate paperwork below (see Support Documentation section).
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SUPPORT DOCUMENTATION
Please provide estimate for equipment, therapy, or service being requested. (Providing this documentation will increase your chances of being approved for a scholarship.)

Please provide estimate for equipment, therapy, or service being requested.
PHOTO FOR SOCIAL MEDIA IF SELECTED FOR SCHOLARSHIP
If you are selected to receive a Will2Walk scholarship, we require that you provide a testimonial and photo/video of you with your new product/service in order to show our sponsors & donors where their donations are going. We will share this via our website and social media channels to further promote the Program.  The photo uploaded now will only be used if you are selected to receive a scholarship and do not provide an updated photo upon request.  (This photo will not be provided to the Scholarship Committee during the selection process.)
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Please upload your photo.
Agreement & Signature
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I hereby apply for a scholarship from the Will2Walk Foundation.

I hereby consent for Will2Walk Foundation to verify the contents of this application.

In return for the consideration of this application, Will2Walk Foundation is allowed to use the Applicant’s name and likeness to advance the charity’s purposes and reporting requirements. This includes information to prospective donor groups and individuals to further the goals of Will2Walk Foundation

If selected for a Will2Walk Scholarship, I agree to provide testimonials and/or share my story via the Will2Walk Foundation.

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Enter Your Initials (First Middle Last)
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Signature Date
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Signature Date

Parent or Guardian Initials (First Middle Last)
Will2Walk Involvement