The information provided in this application is true and correct to the best of my knowledge. I have to the best of my ability contacted all other known funding sources.

Please provide the following additional information:

• Documentation of Diagnosis (Required)– may be uploaded or:
  • emailed: outreach@acok.org or
  • faxed: 405/759-3574 or
  • sent by text: 405/540-2459

• Description of needed equipment (size, color, model etc.)
• Vendor Name, Contact Information and Account Number (if available) or Quote (if available)

Please note: We are not able to purchase items from ebay or make payments to an individual