Home
Donate
Programs
Bruins
Adaptive Skiing
Equipment Loan Program
Family Assistance
Educational Scholarship
2022 Holiday Gift Program
Adaptive Sailing
About
About Duchenne
About Us
Resources
What We Are Funding
Blog
How to Help / Events
Open Farm & Barn April 29th
Your Choices
Plan Your Own Fundraiser
Contact
Family Assistance
*
Indicates required field
Name of Duchenne Patient for whom this request is being made
*
First
Last
Relationship to Duchenne Patient
*
Name of person filling out form
*
First
Last
Treating Physician
*
Phone Number
*
Email
*
Requested Assistance (description of need and cost)
*
Please provide as much detail as possible to help us make an informed decision and be sure to include both description of the need and the cost.
How will this support have an impact on your child's and your family's life?
*
Have you requested funding from any other organizations?
*
Yes
No
Maybe
Have you attempted to have this expense covered by health insurance?
*
Yes
No
Maybe
If yes or maybe, please describe and share outcome of request.
*
If yes, please provide date of denial. If no/maybe, please explain.
*
Is there anything else you think we should know about your request?
*
PLEASE NOTE:
We do
require
a confirmation of diagnosis (physician's letter, genetic testing results, etc.). Once you have submitted this form, please upload the required documents.
Upload File
*
Max file size: 20MB
If you prefer to email or mail in your application and supporting documents, please download the PDF application below.
Submit
Family Assistance Application.pdf
File Size:
136 kb
File Type:
pdf
Download File
Home
Donate
Programs
Bruins
Adaptive Skiing
Equipment Loan Program
Family Assistance
Educational Scholarship
2022 Holiday Gift Program
Adaptive Sailing
About
About Duchenne
About Us
Resources
What We Are Funding
Blog
How to Help / Events
Open Farm & Barn April 29th
Your Choices
Plan Your Own Fundraiser
Contact