Equestrian Aid Foundation

	Financial support is allocated on a case-by-case basis to pay for various essentials, which may include:
	Medical needs
	Insurance
	Food and Housing
	Transportation
	Physical Therapy
	Individuals in all equestrian disciplines, of any age and diverse ethnic backgrounds are all eligible for Foundation support. Our grant recipients are from all walks of life whose common bond is their love of horses.

	Read some Testimonials from grant recipients.


	If you are in need of assistance, please fill out the application form below and hit the SUBMIT button. All fields marked * are required. Privacy Note: The Equestrian Aid Foundation respects the privacy of every individual who applies for assistance and keeps all information private and secure. You may contact Janise Gray, Director of Grant Recipient Services, directly at 1.800.792.6068.


	General Information

*	First Name
*	Middle Initial
*	Last Name
*	Email
	Social Security #
	Home Phone #
	Address 1
	Address 2
	City
	State
	Zip Code
	Assistance Requirements	Describe specific assistance being requested.
	Assistance Length


	Employment Information

	Employer's Name
	Employer's Address 1
	Employer's Address 2
	City
	State
	Zip Code
	Work Telephone


	Medical Information


	Nature of Illness	Please provide brief description of illness.
	Physician's Name
	Physician's Address 1
	Physician's Address 2
	City
	State
	Zip Code
	Date of Birth (mm/dd/yyyy)

	I hereby grant permission to my physician to release any medical information


	Insurance Information

	Insurance Co. Name
	Insurance Co. Address 1
	Insurance Co. Address 2
	City
	State
	Zip Code
	Insurance Co. Phone #
	Type of Policy


	Income Information (per month basis)

	Income (Amount)
	Supplemental Income Type
	Supplemental (Amount)

	I hereby certify that the information provided about is true, and that I am the sole beneficiary of my assistance that is granted by the application.

	Date (mm/dd/yyyy)