Apply for a Grant

Grant Application Form V2

The information in this application is confidential and protected under the Privacy Act. The information is to be used solely by the staff of Walking With Anthony in determining grant eligibility. If you have received this information in error, please destroy the documents or mail the originals to: Walking With Anthony 9903 Santa Monica Blvd. Suite 1024 Beverly Hills, CA 90212.

In an effort to provide the most safe and effective sponsor programs, we require all applicants to complete this application. Information contained on this application will remain confidential. After your application is reviewed, our office will contact you by e-mail or phone. The completion of this application does not guarantee your participation in our grant program.

Contact Information

Contact Person:
Contact Person:
Contact First Name
Contact Last Name

Applicant Information

Injured Person:
Injured Person:
First Name
Last Name

Injury Information

Current employment status:

Hospital Information

Current Employment Info

Past Employment Info

Monthly Income

Your Story

Are you interested in sharing your story with others?

Social Media (Optional)

How can we help?

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