Stroke Survivor Fund Application
First, tell us who is filling out this form
I am
*
Please Select
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
Submitter Full name
*
First Name
Last Name
Submitter Email
*
example@example.com
Submitter Phone Number
*
-
Area Code
Phone Number
Submitter Organization or Company name
*
Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
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
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Survivor 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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Rehabilitation 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 since your stroke?
*
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. Please ensure you are submitting appropriate documentation so that your application processing is not delayed.
Confirmation of diagnosis
*
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We MUST be able to see your full name, date of birth, diagnosis of stroke and the name and signature of a doctor. Acceptable documents could be: a hospital visit or discharge document, or a signed letter from your doctor.
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Proof of insurance or lack of coverage/benefits
*
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Please submit a document showing that your insurance has DENIED coverage for rehabilitative therapies, or that you have EXHAUSTED your benefits allowed for rehabilitative therapies. Do not submit a picture of your insurance card. Other acceptable documents can be: a letter of termination of employment where your name and termination of benefits is stated, a letter from a doctor or your therapist confirming that you do NOT have health insurance coverage.
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Proof of financial need. NOTE: PLEASE ENSURE YOUR SOCIAL SECURITY NUMBER AND ANY OTHER SENSITIVE INFORMATION IS BLACKED OUT OR NOT VISIBLE.
*
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DO NOT SUBMIT PICTURES OF YOUR SOCIAL SECURITY CARD. Acceptable documents are: a paystub that is not older than three months, your latest tax filing with the Social Security Number blacked out, a letter of termination from your employer, a letter from the Social Security Administration confirming unemployment or disability benefits.
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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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