California Rehabilitation Foundation

This form may be completed by any individual who seeks assistance with items needed to enable independence that are not deemed an urgent safety need. California Rehabilitation Foundation may not be able to assist every individual who applies for assistance. Only complete applications will be reviewed.

Contact Information

First Name *

Last Name*

Phone*

Email*

Address*

Street Address

Address 2

City*

State*

Postal Code*

Qualifications

Are you 18 years or older? *

Yes No

I am under 18 years old and this Application is being submitted by my parent/guardian *

Yes No

Insurance has denied payment for the item(s) requested herein *

Yes No

Applicant history *

I am a first-time applicant

I have not received Foundation funding in the past 24 months

Demographic Information (optional)

Are you a citizen of the United States? *

Yes No

Race/Ethnicity

Gender*

Age

Request

EIP grants are awarded for up to $7,000 (limit of one grant per applicant every two years)

Describe your injury, including date, type and how you were injured *

Describe how your injury impacts your everyday life *

Describe the requested equipment and include a link and any specifications *

Upload all the required documents.Allowed file types are(pdf, jpg, jpeg, png).Max no. of files 5

Describe how this equipment or item will enable independence in the home and community (please be as specific as possible) *

If funds are related to minor home modifications, how long do you plan to reside in the home? *

Partial Payments

If funds are for partial payment, please indicate the following

Additional funding source(s) that have approved funding and amount(s)*

Other agencies that you have applied to and time frame for *

Total Amount of Item*

Financial Information

Number of persons in household*

Annual income *

Monthly expenses*

California County you reside in *

Are you currently working? *

Yes No

Referral Source

How did you hear about the Enabling Independence Program? *

If someone recommended this program to you,please mention their name or organization

Relationship with California Rehabilitation Foundation

I confirm that I have no relationship with any director or officer of California Rehabilitation Foundation *

Yes No

Partner with Us

During the process of recovery, one of the most important things we can do is show others they are not alone. Each day, we are inspired by the stories of individuals who demonstrate strength and resilience during life’s most difficult challenges. By partnering with the Cal Rehab Foundation, you can bring the gifts of hope, healing and independence to people with physical disabilities.

Get in Touch

Donate Now

A generous spirit and grateful heart can help transform lives. Your tax-deductible donation to the Cal Rehab Foundation empowers people recovering from illness or injury, especially the most vulnerable and underserved, to rebuild their lives. Whatever the amount, your gift will make a difference!

Donate Now

Non-Immediate Grants

Qualifications

Select all that apply

If applying for home modification(s)

If applying for sports, leisure, and recreation equipment

Contact Information

Qualifications

Demographic Information (optional)

Request

EIP grants are awarded for up to $7,000 (limit of one grant per applicant every two years)

Upload all the required documents.Allowed file types are(pdf, jpg, jpeg, png).Max no. of files 5

Partial Payments

Financial Information

Referral Source

Relationship with California Rehabilitation Foundation

Partner with Us

Donate Now