Apply — Westside Foundation

The Westside Foundation (WF) operates independently and is not associated with Westside Children’s Therapy. The Westside Foundation only has access to information you include on this application.

Application Checklist

Enhance your application using the checklist below:

Does your application clearly describe your commitment to improving your child’s and/or family’s quality of life?
Does your application state what the grant money would be directly used for if awarded (adaptive equipment, co-pays for therapy services, communication devices, sensory support items, etc.)?
Is your request within a reasonable range for our small-scale foundation to award ($3,000 or less)?
Does your application highlight your child’s strengths as well as your child’s challenges?
Does your application include the direct impact the award money would have on your child and/or family?
Does your application include vital health insurance information (if applicable)?

The submission of this form constitutes your "application." Upon submission, your application will be reviewed by the Westside Foundation's Board of Directors. Awards will be announced after the relevant award decision date (March 1, June 1, September 1, December 1). Award Recipients will be notified via email or phone.

If you have an questions or need assistance in completing your application, then please reach out to with an email to misty@westsidegivesback.org and yolanda@westsidegivesback.org. Please do so well in advance of the deadline. They will respond at either of their earliest convenience.

Application

First Name (Parent or Gaurdian)*

Last Name (Parent or Gaurdian)

Email Address

Phone Number (ex. 312-555-1234)

Mobile Number (ex. 312-555-1234)

Home Address

Do you have primary insurance?

Do you have secondary insurance?

How many children do you have?

What is your Annual Household Income?

Child's First Name

Child's Last Name

Child's Date of Birth (ex. 01/01/2010)

How much would you need to benefit your child (in dollars)?

What's your child's diagnosis/condition?

How does this impact daily living and independence for your child?

In general, what are your child’s strengths and challenges?

If selected, what equipment, support services, or therapy services will the financial assistance be used for, and how would this award significantly improve the wellbeing of your child?

How will this award significantly improve the wellbeing of your child? (Please explain in detail.)

Have you applied to the Westside Foundation in the last 12 months? *

Have you received an award from the Westside Foundation in the last 12 months?

Any additional information you would like to share with the board for consideration that was not answered in the above questions?