Shubert’s Kids Grant Application

Name of Applicant (required)

Applicant's Age (required)

Gender (required)

Date of Birth (required) (mm/dd/yyyy)

Disability and/or Diagnosis

Your Address (required)

Your Email (required)

Phone Number

What type of orthotic or prosthetic are you requesting?

Amount requested from Shubert’s Kids? (not to exceed $500)

How did you hear about us?

Complete this section to substantiate and explain your need for devices.

1. Describe the need for orthotic/prosthetic you are requesting:

2. Describe how this product will assist the applicant:

List all private insurance, Medicaid, Early Steps or other insurance that applicant is eligible for:

Reason the above listed insurances do not cover the expense of the orthotic or prosthetic (Note: provide letter of denial from declining agency or other proof why it is a noncovered benefit)

I understand that approval of this request rests with Shubert’s Kids Fund Committee. For lawful purpose of publicity, illustration, advertising and web content, I consent to allow Shubert’s Kids and Dynamic Orthopedics to use name and photos of my child utilizing the orthotic or prosthetic.

By signing the application, the applicant and the applicant’s family declares that the family is in need, has no other means to obtain the devices that are medically necessary and will authorize release of any information to substantiate the request if necessary.

The applicant and the applicant’s family agree not to hold Shubert’s Kids or Dynamic Orthopedics liable for any defects, repairs, malfunctions or injury due to use of the services and product provided through this fund. (Refer to DOI warranty policy)

Signature(required)

Date(required)