CHASA Orthotic Grant Program
You are applying for the Children's Hemiplegia and Stroke Association (CHASA) Orthotic Grant program. Please answer all questions that are relevant or have an * beside them. This form is set up to screen applicants, so depending on your answers, you may or may not be contacted to continue with the program. Submission of this initial form does not guarantee eligibility for a grant or the availability of funding for the grant program. It is our hope that we are able to help you. If your income does not fall within the table listed below, you are not eligible for a grant. Grants are currently limited to U. S. citizens.
Address Line 2
State / Province / Region
Postal / Zip Code
Antigua and Barbuda
Bosnia and Herzegovina
British Indian Ocean Territory
Central African Republic
Democratic Republic of the Congo
Republic of the Congo
Papua New Guinea
Saint Kitts and Nevis
Saint Vincent and the Grenadines
Sao Tome and Principe
Trinidad and Tobago
United Arab Emirates
United States Minor Outlying Islands
Virgin Islands, British
Virgin Islands, U.S.
Email. Please set up your email program to allow emails from email@example.com.
Does your adjusted gross income (AGI) fall within the table below?
Family size (as reported on your IRS 1040)
Adjusted Gross Income (as reported on your IRS 1040)
2 members - AGI $75,000 or less
3 members - AGI $100,000 or less
4 members - AGI $125,000 or less
5+ members - AGI $150,000 or less
Is the child 17 years old or younger?
How old is your child?
Does the child live in the United States and have a Social Security number?
Do you understand that grant awards are retroactive to sixty days prior to the date of application and have an expiration date of approximately 3 months, unless the funds are exhausted prior to the expiration date. The grant will NOT cover any orthotic costs outside of this date range.
Do you understand that the grant payment, if awarded, will be paid directly to the health care provider who provided the orthotic to your child? It will not be paid directly to you.
This initial application is a screening application. You will be asked to provide detailed financial information if you are chosen to continue with the application process. Your child's health care professional may be required to provide medical information as it relates to your child's need for an orthotic. You will need to provide this information to us in a timely manner. Do you understand?
Please describe your private health care insurance, any government sources of health care benefits your child or family receives, and any other sources that help you pay for health care. Include the names of companies and programs. Include details about coverage of orthtotics, deductibles, co-pays, and any other reasons as to why you need assistance with paying for your child's orthotics.
This program currently covers hand and foot orthotics (braces). It does not currently cover any devices that use electrical stimulation. Please describe the type of orthotic your child will require. Include information about your child's medical condition, relating to the need for an orthotic.
What is the approximate cost of your child's orthoic? How much of this amount are you requested through this grant program?
List the healthcare provider or clinic that provides your child's orthotic. Include contact person's name, address, and phone number.
The grant application, approval process, and award of the grant may take several months. When will your child's orthotic be delivered to you and when do you anticipate needing to pay your share of the cost of the orthotic to the provider?
Is this your child's first orthotic? Does your child currently wear an orthotic? Does your child wear more than one orthotic? If so, list number of hand and foot orthotics worn.
What is your child's diagnosis?
Submitting this application does not mean that you have been chosen as a grant recipient. Do you understand?
How did you learn about the CHASA Orthotic Grant Program?
List questions below.
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