Application Form

All requests should be submitted on this form. Please attach any additional information that supports your proposal. Please note, a doctor referral will be requested if appropriate to the request.

Alternatively, you can download a PDF version of this form. Fill out the form and send to

Applicant Information

Is the child or teenager a resident of MA? (Proof of residency may be required) Yes No

Child/teen needing assistance

Check if same as applicant address

If not you, who will be administering the funds?

Check if same as applicant address

Proposal Request Information

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