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  • Senior Support Application

  • Introduction:

    Thank you for your interest in seeking assistance for durable medical equipment from The Kristina Butler Foundation. Our Foundation is dedicated to supporting seniors and helping them thrive. Please complete this application to help us assess your eligibility for our Senior Support Program.

    Application Guidelines:

    • Applications are processed within 30 business days of cycle close.
    • Submission does not guarantee assistance due to limited resources.
    • For detailed assistance policies, please refer to The Foundation’s Assistance Policy here.

    Cycle Information:

    • During this cycle, The Kristina Butler Foundation will be awarding a durable medical equipment (The amount per qualified individual will be determined based on needs identified in this application.)
    • The application submission period for this cycle will be open from February 23, 2026 to March 23, 2026 11:59 P.M. EST

  • Paper applications are available upon request by emailing hello@kristinabutlerfoundation.org. Paper applications can also be mailed to:

    The Kristina Butler Foundation, Inc.

    P.O. Box 17482

    Sarasota, FL 34276

  • I am requesting support for*

  • Your Contact Information

  • Format: (000) 000-0000.

  • Personal Information of the Senior Needing Assistance:

  • Date of Birth*
     - -
  • Format: (000) 000-0000.
  • Is the senior able to receive calls regarding this application?*
  • Best time to call

  • Eligibility Criteria:

  • Has the senior, or anyone in the household, previously received support from The Kristina Butler Foundation?*
  • Has the senior, or anyone in the household, previously requested support from The Kristina Butler Foundation?*
  • Is the senior directly related to a current employee or board member of The Kristina Butler Foundation? This includes spouses, parents, children, siblings, or any other close relatives.*

  • Eligibility Requirements for Seniors:

    To be considered for durable medical equipment support, the senior receiving support must:

    1. Be age 65+.
    2. Reside in the United States.
    3. Demonstrate financial need. 
  • Do you believe the senior meets all the above eligibility requirements?*

  • Health and Functional Status

  • Does the senior need assistance with any of the following? (Select all that apply):*
  • Does the senior have any of the following conditions? (Select all that apply):*

  • Safety and Support:

  • How confident do you feel about the overall safety of the senior's living environment?*
  • Does anyone live with the senior full-time?*
  • Where does the senior currently reside?*
  • Does the senior have family or friends who provide them with support?*
  • Does the senior have a paid caregiver(s) who provides them with support?*
  • How often does the senior participate in community programs or activities?*

  • Needs Assessment:

  • What is the senior's total household income?*
  • What type(s) of income does the senior receive? (Select all that apply)*
  • How often does the senior experience difficulties affording necessary medical expenses?*
  • How often does the senior experience difficulties affording basic living expenses?*
  • What type of insurance does the senior have? (Select all that apply)*
  • What type of equipment are you requesting? (Select all that apply. NOTE: THIS DOES NOT GUARANTEE YOU WILL RECEIVE ANY/ ALL THE SELECTED EQUIPMENT)*
  • 0/500
  • Does the senior have any financial hardships or challenges that make it difficult to afford the equipment you are requesting?*
  • Has the senior exhausted all available insurance coverage options for the requested equipment?*
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  • Electronic Signature:

    By typing your name below, you agree that:

    1. The information you provided in this application is truthful and complete to the best of your understanding.
    2. Submitting this application does not guarantee assistance from The Kristina Butler Foundation.
    3. Any awarded equipment will be used solely for the senior identified in this application.
    4. You have reviewed and agree to the eligibility criteria and liability waiver in the support policy.
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