Application for Assistance

Please complete the form below. Do not submit medical records or other supporting documents through this form. If additional documentation is needed, we will contact you directly.

Facebook

This field is for validation purposes and should be left unchanged.

Applicant Information

Name of Individual in Need(Required)

First Last

Age(Required)

Date of Birth(Required)

Medical Condition

The individual named above has been diagnosed with Duchenne Muscular Dystrophy (DMD), a progressive neuromuscular disorder that results in muscle degeneration and loss of mobility. Due to the progression of this condition, specialized medical equipment and/or an accessible van are essential to maintain quality of life, independence, and safe transportation.

Purpose of Request(Required)

We are respectfully requesting financial assistance for the following (please check all that apply):

Medical Equipment

Accessible Van / Vehicle Modification

Other (please specify)

Please specify the medical equipment needed(Required)

Please specify your needs(Required)

Explanation of Need(Required)

Due to the physical limitations caused by Duchenne Muscular Dystrophy, the individual requires adaptive support for daily living and transportation. The requested equipment/vehicle will:

Improve mobility and accessibility

Ensure safe and reliable transportation to medical appointments, therapy, and daily activities

Enhance overall quality of life and independence

Financial Information

Total Estimated Cost of Equipment/Van(Required)

Amount Currently Available Toward Purchase:(Required)

Source(s) of Available Funds (savings, insurance, fundraising, etc.)(Required)

Amount of Financial Assistance Requested:(Required)

Additional Financial Considerations

Contact Information

Primary Contact Name(Required)

First Last

Relationship to Applicant

Phone Number(Required)

Email Address(Required)