Survivor Fund Application
A fund by The Stroke Foundation dedicated to helping stroke survivors cover some of the costs of physical, speech or occupational therapies for stroke recovery.
About you
Tell us who is filling out this form
I am..
*
A stroke survivor filling out the application for myself
A family member of a stroke survivor filling out the application on behalf of them
A caregiver of a stroke survivor filling out the application on behalf of them
A medical professional of a stroke survivor filling out the application on behalf of them
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Your details
Give us information about yourself
Full name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
-
Area Code
Phone Number
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of birth
*
-
Month
-
Day
Year
Date
Sex
*
Male
Female
I prefer not to disclose
Race
*
American Indian or Alaskan Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
I prefer not to disclose
Ethnicity
*
Hispanic or Latino
Not Hispanic or Latino
I prefer not to disclose
Job status
*
Unemployed
Student
Employed full time
Employed part time
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Your details
Give us information about yourself
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
-
Area Code
Phone Number
Date of birth
*
-
Month
-
Day
Year
Date
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About the stroke survivor
Tell us some more information about the person benefitting from the grant
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
-
Area Code
Phone Number
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of birth
*
-
Month
-
Day
Year
Date
Sex
*
Male
Female
I prefer not to disclose
Race
*
American Indian or Alaskan Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
I prefer not to disclose
Ethnicity
*
Hispanic or Latino
Not Hispanic or Latino
I prefer not to disclose
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Grant specific questions
Give us some more details about the need for physical, speech or occupational therapy.
Date of stroke
*
-
Month
-
Day
Year
Date
Do you have insurance?
*
Yes
Yes, but I don't have coverage or benefits for physical therapy, occupational therapy, or speech therapy.
No
What therapies do you need for recovery? Select any that apply.
*
Physical therapy
Speech therapy
Occupational therapy
Are you currently in physical therapy, speech therapy or occupational therapy?
*
Yes
No
Have you done physical therapy, speech therapy or occupational therapy in the past?
*
Yes
No
Where was therapy done? Select any that apply.
*
Inpatient at a hospital or clinic
Outpatient
At home
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Document uploads
We require certain documentation in order to complete your application. To learn which documents are acceptable, please click the link at the beginning of the form or visit our website.
Confirmation of diagnosis
*
Browse Files
Drag and drop files here
Choose a file
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of
Proof of insurance or lack of coverage/benefits
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Proof of financial need. NOTE: PLEASE ENSURE YOUR SOCIAL SECURITY NUMBER AND ANY OTHER SENSITIVE INFORMATION IS BLACKED OUT OR NOT VISIBLE.
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
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Personal statement
Please use this space to write us a personal statement on how the grant would improve your stroke recovery.
*
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Please sign to submit the application.
*
Submit
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