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California Rehabilitation Foundation
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

01

Contact Information

02

Qualifications

03

Demographic Information (optional)

04

Request

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

05

Financial Information

06

Referral Source

07

Relationship with California Rehabilitation Foundation

* 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.

California Rehabilitation Foundation

2070 Century Park East
Los Angeles, CA 90067