IAA Funds Request Form

[contact-form to=”wday@miicor.com” subject=”IAA Funds Request Form”]

Applicant Information

[contact-field label=”Name” type=”name” required=”1″][contact-field label=”Address” type=”text” required=”1″][contact-field label=”City, State, Zip” type=”text” required=”1″][contact-field label=”Phone / Email” type=”text” required=”1″][contact-field label=”Request Funds For” type=”textarea” required=”1″][contact-field label=”Amount Requested” type=”text” required=”1″][contact-field label=”Physician treating Rheumatologic disease” type=”text” required=”1″]
(If physician recommended please submit/attach prescription or letter from physician)

Funds will be paid to the Vendor on your behalf:
[contact-field label=”Name” type=”text”][contact-field label=”Address” type=”text”][contact-field label=”City, State, Zip” type=”text”][contact-field label=”Phone” type=”text”][contact-field label=”Fax | Email” type=”text”][contact-field label=”Additional Comments” type=”textarea”]

Requestor Signature

[contact-field label=”Legal Name” type=”text” required=”1″][contact-field label=”Date” type=”date” required=”1″]
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).
[/contact-form]

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