Senior Support Application

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 15, 2025 to March 23, 2025 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*

MyselfSomeone else
Your Contact Information
What is your name? *

First NameLast Name
What is your phone number?*
Please enter a valid phone number.
What is your email address?
example@example.com
What is your relationship to the person you are requesting assistance for?*
Personal Information of the Senior Needing Assistance:
Full Legal Name*
Include all applicable: First, Middle, Last, Suffix
Date of Birth*

MonthDayYear
Physical Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Is the senior able to receive calls regarding this application?*

YesNo
Best time to call

MorningAfternoonEveningAnytimeOther
Email
example@example.com
Eligibility Criteria:
Has the senior, or anyone in the household, previously received support from The Kristina Butler Foundation?*

YesNo
Has the senior, or anyone in the household, previously requested support from The Kristina Butler Foundation?*

YesNo
Name of the person who previously requested support *
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.*

YesNo
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?*

YesNo
Health and Functional Status
Does the senior need assistance with any of the following? (Select all that apply):*

Bathing, grooming & dressingMobility Assistance: ambulation, transferring, etc.Toileting & continence careMedication reminders / managementHousekeepingShopping / errandsTransportationCompanionship and emotional supportMeal preparation / feedingExercise / range of motionSafety AssistanceManaging FinancesNone of the aboveOther
Does the senior have any of the following conditions? (Select all that apply):*

Cognitive Limitations: Alzheimer's Disease or DementiaChronic Illness: Cancer, diabetes, heart disease, etc.Mental Health ConditionsMobility issues, arthritis, osteoporosisParkinson's DiseaseStrokeHearing Impairment / DeafSpeech ImpairmentVision Impairment / BlindParalysisNone of the aboveOther
Safety and Support:
How confident do you feel about the overall safety of the senior's living environment?*

Very ConfidentConfidentSomewhat ConfidentNot Confident At All
Does anyone live with the senior full-time?*

YesNo
Where does the senior currently reside?*

Private residence (home, condo, apartment, townhome, etc.)Independent living communityAssisted living facilityNursing homeOther
Does the senior have family or friends who provide them with support?*

All the timeMost of the timeSometimesRarelyNever
Does the senior have a paid caregiver(s) who provides them with support?*

All the timeMost of the timeSometimesRarelyNever
How often does the senior participate in community programs or activities?*

DailyWeeklyMonthlyQuarterlyAnnuallyNever
Needs Assessment:
How many dependents does the senior support?*
What is the senior's total household income?*

Below $25,000$25,000 - $49,999$50,000 - $59,999$60,000 - $74,999$75,000 - $84,999$85,000 - $94,999$95,000 - $104,999$105,000 - $114,999$115,000 - $124,999$125,000+
What type(s) of income does the senior receive? (Select all that apply)*

Social SecurityDisabilityPensionNo sources of incomeOther
How often does the senior experience difficulties affording necessary medical expenses?*

FrequentlyOccasionallyRarelyNever
How often does the senior experience difficulties affording basic living expenses?*

FrequentlyOccaisionallyRarelyNever
What type of insurance does the senior have? (Select all that apply)*

MedicareMedicaid / MediCalPrivate Health InsuranceNo Health InsuranceOther
What type of equipment are you requesting? (Select all that apply. NOTE: THIS DOES NOT GUARANTEE YOU WILL RECEIVE ANY/ ALL THE SELECTED EQUIPMENT)*

WheelchairCaneWalkerGait BeltSlide BoardBedside CommodeShower ChairRaised Toilet SeatLift ChairHoyer LiftMotorized ScooterGrab BarsClean Cut BathtubHospital BedRampPersonal Safety AlertLong Reach Comfort WipeReacher / GrabberFleece Seat CushionOther
Tell us why the requested equipment will improve the senior's quality of life and / or independence. (Answers should be at least 5 words and up to 500 words maximum)*

0/500
Does the senior have any financial hardships or challenges that make it difficult to afford the equipment you are requesting?*

No Financial HardshipsMinor Financial HardshipsModerate Financial HardshipsSignificant Financial Hardships
Has the senior exhausted all available insurance coverage options for the requested equipment?*

YesNo
Is there anything else you would like to share about the senior's situation?
You are welcome to upload any additional documents that should be considered in your application.

Cancelof
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.
Electronic Signature [Type your full name here:]*
First Name, MI, Last Name, Suffix
Form Total
Should be Empty:

Senior Support Application

Your Contact Information

Personal Information of the Senior Needing Assistance:

Eligibility Criteria:

Health and Functional Status

Safety and Support:

Needs Assessment: