Help CP.org

Grant Application

YOUR INFORMATION

Application Type

Please check the fund you are applying for

Help CP.ORG

Shubert's Kids (prosthetic and orthotic devices)

Today's Date

YYYY

Your Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Candidate Information

Name

First Name

Last Name

Diagnosis

Date of Birth

YYYY

When was your child diagnosed?

YYYY

Diagnosing Physicians Name and address:

Type of Health Insurance Coverage?

Child's relationship to you?

Does your child currently receive any government assistance?

Yes

Section

How much is the total amount of out of pocket medical expenses paid on behalf of this child in the last 12 months?

Family Information

Mother's Name

First Name

Last Name

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Place of Employment

Occupation

Father's Name

First Name

Last Name

Address 2

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Place of Employment

Occupation

Annual Household Income before Taxes (for all members of the household)

Number of people in the household

Please list the names and ages of each sibling:

Request for Funding

Please describe in detail what services, medical devices, or therapies you are seeking funding for:

What is the total cost of the services you are requesting?

Please give the contact information for the provider you will be purchasing these services or products from:

Hold Harmless Agreement

I willfully accept a donation from Help Troy, Inc. I am aware of any and all inherent dangers and risks involved with my request for a donation from Help Troy, Inc. including, but not limited to: bodily injury to the eyes, nose, head, neck or back; sprains, fractures, breaks, or dislocations of the joints or limbs; lacerations, concussions, any further medical conditions that may occur or death. I understand that Help Troy, Inc. does not provide any Accident or Medical Insurance and that I am solely responsible to provide it for my child. I agree, on behalf of my child, and our assigns, executors and heirs, to indemnify and hold harmless Help Troy, Inc. and it's directors form any and all liability, damage and claims of any nature arising out of or in any way related to my child's participation in this type of therapy, treatment, and/or activity.

Hold Harmless

I Agree to and understand the Hold Harmless Agreement.

Shubert's Kids Fund: helping children obtain prosthetics and orthotic devices. Proud partner of Dynamic Orthopedics. — Shubert's Kids Fund: helping children obtain prosthetics and orthotic devices. Proud partner of Dynamic Orthopedics.