Apply for Funds — PMRCharity

Application Process

Currently, we only supply funding to specific counties. Click here to see this map with the counties we service.

Once you fill out the form below, our system will follow up. This form is not your submission for funding. You will get an email after you submit the form from DocuSign to start the process of submitting your application.

IMPORTANT: If you are filling out this form on someone's behalf, you must use the applicant's name and email address. If they do not have an email address, please have the applicant create one or create one for them. Our system can only track applications having their unique email.

If you run into any issues or need support, please email: pmrcharity@yahoo.com

First Name

Last Name

Phone

(###)

###

####

County

Name of guardian and relationship if applicant is a minor (under 18 years of age):

Reason for Applying?

Please give us a short description of your diagnosis and why it has been hard to get funding.

How did you hear about PMR Charity?

If you selected case manager, medical professional, or healthcare company please specify.

Application Process

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