Application for Financial Assistance

Client's Name*

First Last

Age*

Date of Birth*

Male
Female

Race*

Asian
Black or African American
Native American or Alaska Native
Native Hawaiian or Pacific Islander
White
Two or more races
Undisclosed/Other

One of the Equipment Fund’s primary funders is now requesting that we collect information on race and ethnicity. This will not affect the services you receive. This information is confidential, and no personal identification will be shared.

Ethnicity*

Hispanic or Latino
Non-Hispanic or Latino

Address*

Street Address City County State ZIP Code

Phone*

Email*

Parent's Name(s) (if client is a minor)

Father's Place of Employment*

Mother's Place of Employment*

Client's Place of Employment*

Disability or Diagnosis*

Date of Onset of Disability (at birth or other, if other- please specify)*

Equipment Requested*

Name of Vendor

Please attach estimate or quote if available.

Max. file size: 8 MB.

Total Cost*

Amount Family Can Contribue Toward Cost*

Amount Requested from CPRF*

Have any other agencies or groups been contacted for assistance?*

Yes
No

If yes, which agencies and what was the outcome?

Will your personal insurance cover any or all of the equipment?*

Yes
No

If yes, how much?

Name of Insurance Company

Is the client eligible for and/or receiving assistances from (please check all that apply):

Kansas Rehabilitation Services
Social Security
Medicaid (KanCare)
Supplemental Security Income (SSI or SSDI)
KS Children & Youth with Special Health Care Needs
Medicare

Do you have a prescription or professional recommendation for the item requested?*

Yes
No

If yes, from whom?

Gross Family Income*

Number of Persons Living in Household*

I verify that the information provided above is accurate and I agree to complete a follow-up questionnaire if provided with financial assistance. I also grant the Cerebral Palsy Research Foundation of Kansas permission to communicate and share information with funding sources and/or vendors listed above.*

I Agree

Signature*

Date*