Application2

The

Kaitlin Marie Bell Foundation, Inc.

Helping children with disabilities of Delmarva & the Eastern Shore

"WE ARE NOT ACCEPTING APPLICATIONS AT THIS TIME"

Application for Assistance

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
Applicants 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 *
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


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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.
W2 Form is Required. Your application cannot be considered without it. We keep all information guarded and confidential

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
A PDF File will be coming soon of Application for download Please use the above application for now

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