Medical Equipment Assistance

The medical equipment assistance program is for families that need help paying for medical equipment that a child needs on a day to day basis. We may ask you to prove your financial needs to make sure our funds are used in the most appropriate way. We will only pay the medical bill directly to the vendor and we may not be able to cover the entire cost. Please submit the request below and we will get back to you as soon as possible to let you know if you qualify.

Parent/Guardian Name*
First Last
Child's Name*
First Last
Child's Date of Birth*
MM slash DD slash YYYY
Child's Diagnosis*
Address*
Street Address Address Line 2 City State ZIP Code
Email*
Phone*
Total Household Income*
What is the child in need of?*
Why do you need the assistance?*
How would this assistance affect the child's day to day life?*
How did you hear about the program?
Consent*
I agree to the privacy policy.
Hidden
formname