California Rehabilitation Foundation

This form may be completed by any individual who seeks assistance for urgently needed items deemed necessary to keep you safe in your home. California Rehabilitation Foundation may not be able to assist every individual who applies for assistance. Only complete applications will be reviewed.

URGENT QUESTIONNAIRE

Accurate measurements have been taken to ensure equipment fits into designated space.
Insurance has denied coverage
Letter of medical support and/or prescription
Able to prove financial hardship, if requested
If Yes, to all of the items above, please complete the application below in its entirety. If No, please send an email to info@calrehabfoundation.org with more information.

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 have a prescription from a physician for the item(s) requested herein *

Yes No

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

Yes No

Applicant history *

I am a first-time applicant

No 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)

Please describe your injury, including the date of injury, type, and how you were injured *

Describe how your injury impacts your everyday life? *

Describe the requested equipment and include a link, along with any specific requirements*

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

Describe how the equipment will enhance independence at home and in the community *

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

* Please keep in mind, that once Foundation funds are utilized to purchase equipment, all transactions are final. Returning of equipment will not be allowed.

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.

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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!

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Urgent Grants

URGENT QUESTIONNAIRE

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

Financial Information

Referral Source

Relationship with California Rehabilitation Foundation

Partner with Us

Donate Now

California Rehabilitation Foundation

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