Application for Assistance

NOTICE Effective March 1, 2003, the maximum award The Kaitlin Marie Bell Foundation, Inc. will distribute to each recipient whose applications have been approved by the board of directors is $500. There will be two $500 awards given per year and the recipients of these awards will be given notification in writing of their approved application. For an application to be eligible for review by the board of directors, it must be complete and received no later than June 30th for a July 15th disbursement and August 30th for a September 15th disbursement. This policy change is not permanent and it will be re-assessed annually. The application review process will be unchanged (See Below For More Details). The disbursement of funds from The Kaitlin Marie Bell Foundation, Inc. to recipients up to the age of 21 will consist of the entire board reviewing the information provided on the application and the board members voting to award or deny the request. The vote must be a majority vote. Upon receipt of an application, information provided will be reviewed, and if necessary, verified, including: income documents, letters of denial for insurance coverage, any other sources of assistance attempted, letters from physicians, teachers, therapists, or any other outside professionals involved with the child's care, to assess the child's needs for assistance. However, the majority vote of the board will not depend solely on the preceding information as other circumstances may apply. Companies and organizations that provide equipment or services needed by the applicant will be contacted for information on price and availability. Attempts will also be made to locate discounts or donations of equipment or services so that we can better meet the needs of more children and their families. Upon receipt of equipment or service availability, the applicant shall be awarded such equipment or services. With applications that are denied, a letter will be sent to the applicant regarding the board's decision. Applicants who wish to re-apply must provide additional documentation that the child or family's circumstances have changed or that all other possible alternatives have failed. E-mail Address: * Applicant Name - Last, First, Middle * Date of Birth: * Sex * Male Female Applicant Address: * City * State * Zip * Residence * House Apartment Rent Own Primary Caregivers Name - Last, First, Middle * Additional Caregivers Name - Last, First, Middle Is caregiver the parent? * Yes No If no, what is the relationship of caregiver to applicant? Is caregivers address the same as above? * Yes No Caregivers address if different than above City State Zip Email Address * Caregivers telephone Home * Caregivers telephone Work Applicant's diagnosis Complications related to diagnosis Specific equipment and/or service requested (please provide exact name of the equipment/service requested, the name of the manufacturer or provider, and the name, address, and telephone number of the vendor through whom you will obtain equipment or service): Estimated cost of equipment and/or service: Have you or will you receive any other funding from other organizations, friends or family Please provide information regarding all steps taken to obtain equipment and/or services for the applicant (insurance requests, other organizations attempted, etc.) Please indicate any special circumstances you feel are pertinent to this request Financial Information   Annual Salary (if more than one caregiver, what are the combined salaries) * Pension, unemployment, workmans comp. Place a Zero if none * Social Security, S.S.I., Disability DO PLACE Social Security Number here Place a Zero if none * Public Assistance Place a Zero if none * Public Assistance Source Child Support Place a Zero if none * Annual Gross Household Income including all sources * Number of people currently being provided for on this income * Applicants health care coverage * No Health Care Coverage Medicaid Medicare Private Specify below Other Specify below Specify Private or Other Coverage information from above question if it applies Is there a deductible Yes No If yes, what is the deductible Check list of provided information I have pertaining to this request, including a recent letter from the childs physician explaining medical necessity, and/or a letter from a health care professional explaining how the applicant would benefit from the equipment and/or service you have requested * A letter of denial from the childs insurance provider, which states that the requested equipment and/or service was denied * Proof of all income * Any other documentation pertaining to the child or nature of the request. * I understand that the above information is required Applications that are not completed in full or missing requested additional information will not be reviewed until complete * I will submit this application via email and also print and mail with all required information * By submitting this electronic form you attest that the information you have provided in this application is factual and true to the best of your knowledge * Required Powered by myContactForm.com In a seperate postal mail, please provide all information you have pertaining to this request, including: a recent letter from the child's physician explaining medical necessity, and/or a letter from a health care professional explaining how the applicant would benefit from the equipment and/or service you have requested, a letter of denial from the child's insurance provider, which states that the requested equipment and/or service was denied, proof of all income, and any other documentation pertaining to the child or nature of the request. This information is required -- Applications that are not completed in full or missing requested additional information will not be reviewed until complete. Addendum to Application: By awarding finances, The KMB Foundation is making no recommendation as to the appropriateness or safety of a particular piece of equipment, for each applicant. The KMB Board is not responsible for the safety and use of the equipment or progress of the child. Each family is strongly urged to consult with their physician and therapist regarding the choice and use of specific equipment. We will not divulge names or any other information on any applications or requests that we receive without written consent from the applicant or their legal guardian. Please send the required documentation to: The Kaitlin Marie Bell Foundation, Inc. 8966 Dolby Road Seaford, Delaware 19973 If you have any questions, please call (302) 629-5493 By submitting this electronic form you attest that the information you have provided in this application is factual and true to the best of your knowledge

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