Clone of 2025 U.S. Treatment Grant Application

1
Grant Applicant's Full Name* This field is required.
First Name
Last Name
2
Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
3
Date of birth* This field is required.
Date
4
Email* This field is required.You will be contacted via this email provided if you receive a treatment grant, so please be sure to provide an accurate and up to date email address.
example@example.com
Email Verified
The verification code has been sent to some@email.com
Please check your mailbox and paste the code below to complete verification
••••
Didn't receive verification code?or
Receiving the email may take a few minutes, thank you for your patience!
5
Phone Number* This field is required.
6
Have you been diagnosed with Lyme disease or any other tick-borne illness?* This field is required.*If you have not yet been diagnosed with a tick-borne illness, please apply for a testing grant at lymetreatmentfoundation.org/testing
Yes
No
7
Have you been diagnosed with any co-infections?* This field is required.
Yes
No
8
Please check off the co-infections you have tested positive for (if applicable)Skip this question if you have not yet been diagnosed with a co-infection.
Alpha Gal Syndrome (Red Meat Allergy)
Anaplasma
Babesia
Bartonella
Colorado Tick Fever
Ehrlichia
Mycoplasma
Powassan Virus
Q- Fever
Rocky Mountain Spotted Fever
Tick-borne Relapsing Fever
Tularemia
PANS/PANDAS
Other
9
Check the symptoms that you are currently experiencing:* This field is required.
Air hunger
Anxiety
Cardiovascular symptoms
Daily pain
Depression
Fatigue
Gastrointestinal symptoms
Hallucinations
Light Sensitivity
Neuropathy
Other neurological symptoms
Obsessive compulsive disorder
Other psychiatric symptoms
Seizure-like activity
Suicidal thoughts
Weight loss
Weight gain
Seizures
Eating disorder, such as anorexia nervosa or bulimia nervosa
Other
10
How many years have you been sick?* This field is required.
Less than 1 year
1-2 years
2-5 years
5-10 years
10 or more years
11
Are you currently using a wheelchair to get around?* This field is required.
YESNO
12
Are you able to drive a car every day?* This field is required.
YESNO
13
Are you able to work/attend school?* This field is required.
YESNO
14
Website or social media pages (optional)Share any blog, website, business, or social media pages you may have.
15
Do you currently see a Lyme literate physician?* This field is required.Please provide the doctor's full name, title and phone number.
Ex: Dr. Smith, MD xxx-xxx-xxxx
16
Have you had a blood test done through IGeneX or Armin Labs?* This field is required.
YESNO
17
Are any of your immediate family members sick with Lyme disease or any other co-infections?* This field is required.
YESNO
18
Please discuss your life with Lyme disease and how a grant from Lyme Treatment Foundation would benefit you or your family. (You may also upload a file on the next slide if you have your answer prepared in a word document).
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19
File Upload* This field is required.Please upload a physician's letter stating your tick-borne illness diagnosis. This letter must be on an official letterhead. You may also upload a positive tick-borne illness blood test with your first and last name in place of a doctors note.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
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20
Please upload a document discussing your life with Lyme disease. You may skip this if you have written your story in the previous slide.
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Max. file size: 10.6MB
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21
Upload any supplemental information, such as letters of support from family or members in your community who know you and your Lyme disease situation best.* This field is required.
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Max. file size: 10.6MB
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22
Upload a photo (optional)
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Max. file size: 10.6MB
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23
List your families gross annual income.* This field is required.
24
Upload the first page of you 1040 federal tax return, or documentation of participation in medicaid, social security disability, food stamps, or other similar government program below.* This field is required.Please black out your social security number and any other sensitive information on all documents that you are uploading.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
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25
Have you applied for a Lyme Treatment Foundation grant with us before?* This field is required.
YESNO
26
Have you received a Lyme Treatment Foundation treatment grant before?* This field is required.
YESNO
27
Have you received a Lyme Treatment Foundation testing grant before?* This field is required.
YESNO
28
Do you have any other sources of income, or have you received any funds, grants, etc. from another organization, an individual, a crowd funding site, or government organization?* This field is required.
29
Please explain any other financial hardships you think Lyme Treatment Foundation should know about below.
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30
Please briefly explain how a grant from the Lyme Treatment Foundation would help you.
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31
Signature* This field is required.By signing below, I certify that all information provided is true and correct and that all documents submitted have been untampered with.
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