IAA Funds Request Form

Applicant Information

(If physician recommended please submit/attach prescription or letter from physician)

Funds will be paid to the Vendor on your behalf:

Requestor Signature

NOTE: To be eligible for funding requests you need to be currently treated by a physician for a Rheumatologic disease. This funding is not for medical equipment for medications. Funds are for promotion of community awareness and exercise for the patient only (i.e., gym membership, athletic shoes, exercise equipment, support groups and functions).

You can also download the form by clicking on this link, fill out the form, and then submit it by emailing to idahoarthritiswalk@gmail.com. Or, you can mail it to Idaho Arthritis Walk –
3277 E Louise Dr, Suite 350 Meridian, Idaho 83642